Methods and compositions for treatment of skin disorders

ABSTRACT

The invention provides methods and compositions for the treatment of a skin disorder associated with detrimental TNFα activity, such as psoriasis. The invention includes methods for treating a skin disorder associated with detrimental TNFα activity, such as psoriasis, in a subject who has failed or lost response to prior biologic therapy, such as prior administration of etanercept. The invention further provides methods for determining the efficacy of a human TNFα antibody, or antigen-binding portion thereof, for the treatment of a skin disorder associated with detrimental TNFα activity, such as psoriasis.

RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.12/646891, filed Dec. 23, 2009, which is continuation-in-part of U.S.application Ser. No. 12/352503, filed Jan. 12, 2009, and U.S.application Ser. No. 12/402408, filed Mar. 11, 2009. U.S. applicationSer. No. 12/646891 claims the benefit of priority to U.S. ProvisionalApplication No. 61/140606, filed Dec. 23, 2008, and U.S. ProvisionalApplication No. 61/183446, filed Jun. 2, 2009. U.S. application Ser. No.12/352503 is a continuation of U.S. application Ser. No. 12/130,831,filed on May 30, 2008, which claims the benefit of priority to U.S.Provisional Application No. 60/932914 filed on Jun. 1, 2007; U.S.Provisional Application No 61/011538, filed Jan. 17, 2008; U.S.Provisional Application No. 61/024122, filed Jan. 28, 2008; and U.S.Provisional Application No. 61/128498, filed May 22, 2008. U.S.application Ser. No. 12/402408 is a continuation of U.S application Ser.No. 11/880,433, filed on Jul. 20, 2007, which is a continuation in partof U.S. application Ser. No. 11/786445, filed Apr. 10, 2007. U.S.application Ser. No. 11/786445 claims the benefit of priority to U.S.Provisional Application No. 60/790909 filed on Apr. 2, 2006; U.S.Provisional Application No. 60/809770 filed on May 30, 2006; U.S.Provisional Application No. 60/815489 filed on Jun. 20, 2006; U.S.Provisional Application No. 60/817891 filed on Jun. 29, 2006; U.S.Provisional

Application No. 60/840122 filed on Aug. 25, 2006; U.S. ProvisionalApplication No. 60/899262 filed on Feb. 2, 2007; and U.S. ProvisionalApplication No. 60/909683 filed on Apr. 2, 2007. U.S. application Ser.No. 11/880,433 also claims priority to U.S. Provisional Application No.60/849671, filed on Oct. 4, 2006; U.S. Provisional Application No.60/832370, filed on Jul. 20, 2006; U.S. Provisional Application No.

60/851830, filed on Oct. 12, 2006; and U.S. Provisional Application No.60/857352, filed on Nov. 6, 2006. The contents of all theabove-mentioned priority applications are hereby incorporated byreference in their entirety.

BACKGROUND OF THE INVENTION

Psoriasis is a chronic, immune-mediated disease affecting 1-3% of thepopulation worldwide (Jacobson and Kimball, Epidemiology: Psoriasis In:Psoriasis and Psoriatic Arthritis (Eds: Gordon K B, Ruderman E M).Springer-Verlag Berlin Heidelberg, Germany;2005:47-56), with thegreatest disease prevalence occurring in North America and Europe(Krueger and Duvic, J. Invest. Dermatol, 102:145-185, 1994). The mostcommon form of psoriasis is plaque-type psoriasis, present in 65-86% ofpatients and characterized by the presence of thick, scaly plaques.Based on the National Psoriasis Foundation's definitions of moderate tosevere psoriasis, the prevalence of moderate to severe psoriasis in theUnited States is estimated at 0.31% of persons age 18 or older (Stem etal., J. Investig. Dermatol. Symp. Proc. 9:136-139, 2004). Patients withpsoriasis report reduction in physical functioning and mentalfunctioning comparable to that observed in patients with cancer,arthritis, hypertension, heart disease, diabetes, and depression (Rappet al., J. Am. Acad. Dermatol. 41(3Pt1):401-407, 1999). In a U.S. surveyof the impact of psoriasis on quality of life, respondents reporteddifficulties in the workplace, difficulties socializing with familymembers and friends, exclusion from public facilities, difficulties ingetting a job, and contemplation of suicide (Krueger et al., Arch.Dermatol., 137:280-284, 2001).

Traditionally, treatment for psoriasis has included medications thatsuppress the growth of skin cells. Treatment approaches for psoriasisoften include creams and ointments, oral medications, and phototherapy.

In recent years, biologic response modifiers that inhibit certaincytokines have become a potential new avenue of treatment for psoriasispatients. For example, tumor necrosis factor (TNF) is a cytokineinvolved in inflammatory response and scientific evidence suggests itplays a fundamental role in the pathogenesis of psoriasis (Kreuger etal. (2004) Arch Dermatol 140:218; Kupper (2003) N Engl J Med 349:1987).The advent of targeted biologic therapies has made a significant impacton the treatment options for psoriasis, including moderate to severepsoriasis. In the United Kingdom, for example, the National Institutefor Health and Clinical Excellence (NICE) recommends etanercept, a humanrecombinant TNF receptor fusion protein, for patients with moderate tosevere psoriasis who have failed conventional therapies. Etanercept isnot, however, effective in every patient. Thus, there remains a need formore effective treatment options in patients suffering from psoriasis.

SUMMARY OF THE INVENTION

There remains a need for an effective and safe treatment option forpatients suffering from skin disorders in which TNFα activity isdetrimental, such as psoriasis and psoriasis related disorders, who havefailed or lost responsiveness to an initial treatment, such as treatmentwith a biologic therapy. Treatment of psoriasis with systemic therapy,such as methotrexate or cyclosporine, or biologic therapy, such asefalizumab, can be limited by lack of efficacy or precluded by sideeffects. Other types of therapy, for example ultraviolet light therapy,is often inconvenient. The instant invention provides improved methodsand compositions for treating skin disorders in which TNFα activity isdetrimental, such as psoriasis and psoriasis related disorders, innon-responders.

In one aspect, the invention provides a method for treating a skindisorder in which TNFα activity is detrimental, e.g., psoriasis, in asubject who has failed to respond to or has lost responsiveness to abiologic therapy, comprising administering to a subject in need thereofa human TNFα antibody, or antigen binding portion thereof, such thattreatment occurs.

The invention also provides a method of treating a subject who hasfailed or has become intolerant to phototherapy or systemic therapy,e.g., etanercept or methotrexate, comprising administering to a subjectin need thereof a human TNFα antibody, or antigen binding portionthereof, such that treatment occurs.

In one embodiment, the biologic therapy is etanercept. In oneembodiment, the patient received entanercept therapy following a failureto respond to conventional psoriasis therapy.

In one embodiment, the subject failed to achieve a PASI 50 response rateafter treatment with the biologic therapy. In certain embodiments, thesubject failed to achieve a PASI 50 response rate after treatment withthe biologic therapy, for example, for at least 6 weeks, at least 8weeks, or at least 12 weeks.

In one embodiment, the subject who has failed prior therapy has a PASIof ≧10. In one embodiment, the subject who has failed prior therapy hasa PASI ≧10 and/or a DLQI >10.

In one embodiment, the ahuman TNFα antibody, or antigen binding portionthereof, is administered using a multiple dose regimen comprising atleast one induction dose and at least one treatment dose. In oneembodiment, the induction dose ranges from about 80 to about 160 mg. Inone embodiment, the treatment does ranges from about 40 to about 80 mg.In another embodiment, the human TNFα antibody, or antigen bindingportion thereof, is administered subcutaneously. In another embodiment,the treatment dose is administered one week following the inductiondose. In yet another embodiment the treatment or induction dose is afixed dose.

In another aspect, the invention provides a method of determining theefficacy of a TNFα inhibitor, e.g., human TNFα antibody, orantigen-binding portion thereof, for treating psoriasis in a subject whohas failed to respond or has lost responsiveness to a biologic therapycomprising, determining the PASI, e.g.,PASI50, of a subject or patientpopulation who failed to respond to or lost responsiveness to a biologictherapy and who were administered the human TNFα antibody, orantigen-binding portion thereof, wherein a statistically significantimprovement in the PASI of the patient population indicates that theTNFα inhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, is an effective for treating psoriasis in the subject. In oneembodiment, the biologic therapy is etanercept.

In one embodiment, the human TNFα antibody, or antigen-binding portionis a human antibody, or antigen-binding portion thereof, thatdissociates from human TNFα with a Kd of 1×10⁻⁸M or less and a Koff rateconstant of 1×10⁻³ s⁻¹ or less, both determined by surface plasmonresonance, and neutralizes human TNFα cytotoxicity in a standard invitro L929 assay with an IC₅₀ of 1×10⁻⁷ M or less. In one embodiment,the TNFα antibody, or antigen-binding portion thereof, is a humanantibody, or antigen-binding portion thereof, having the followingcharacteristics: dissociates from human TNFα with a Koff rate constantof 1×10⁻³s⁻¹ or less, as determined by surface plasmon resonance; has alight chain CDR3 domain comprising the amino acid sequence of SEQ ID NO:3, or modified from SEQ ID NO: 3 by a single alanine substitution atposition 1, 4, 5, 7 or 8 or by one to five conservative amino acidsubstitutions at positions 1, 3, 4, 6, 8 and/or 9; and has a heavy chainCDR3 domain comprising the amino acid sequence of SEQ ID NO: 4, ormodified from SEQ ID NO: 4 by a single alanine substitution at toposition 2, 3, 4, 5, 6, 8, 9, 10 or 11 or by one to five conservativeamino acid substitutions at positions 2, 3, 4, 5, 6, 8, 9, 10, 11 and/or12. In one embodiment, the TNFα antibody, or antigen-binding portionthereof, is a human TNFα antibody, or antigen-binding portion thereof,comprising a light chain variable region (LCVR) comprising the aminoacid sequence of SEQ ID NO: 1 and a heavy chain variable region (HCVR)comprising the amino acid sequence of SEQ ID NO: 2.

In another embodiment, the human TNFα antibody, or antigen bindingfragment thereof, is adalimumab, or an antigen binding portion thereof.In one embodiment, the human TNFα antibody, or antigen binding fragmentthereof, is golimumab.

The invention also provides improved methods of treatment, includingmethods of improving disease reduction in patients having psoriasis andimprovements in quality of life the psoriasis patients. The inventionprovides a method of improving a DLQI score of a subject havingpsoriasis from a large/extremely large score to a no or small impactscore comprising administering a TNFα inhibitor, e.g., human TNFαantibody, or antigen-binding portion thereof, to the subject, such thatthe DLQI score improves from the large/extremely large score to the noor small impact score. The invention also provides a method ofdecreasing a Physician's Global Assessment (PGA) score of a subjecthaving psoriasis by at least about 2 points comprising administering aTNFα inhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, to the subject, such that the PGA score is decreased by atleast about 2 points. The invention also includes a method of improvinga Psoriasis Area and Severity Index (PASI) score of a subject havingpsoriasis by at least about 8 points comprising administering a TNFαinhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, to the subject, such that the PASI score is improved by atleast about 8 points.

The invention provides a method for treating certain subpopulations ofpatients, including, for example, those who have failed prior therapy orhave had a subtherapeutic response. The invention includes a method oftreating a subtherapeutic response to an original dose of a TNFαinhibitor, e.g., a human TNFα antibody, or an antigen-binding portionthereof, in a subject having psoriasis comprising administering the TNFαinhibitor to the subject at an increased dosing rate which is abouttwice as frequent as the original dosing rate. In one embodiment, theincreased dosing rate is weekly. In one embodiment, the subtherapeuticresponse is defined as less than a PASI 50 response determined betweenbaseline (week 0) and a time period following baseline. In oneembodiment, the response is determined between baseline and at leastabout 24 weeks following baseline.

The invention further includes a method of achieving a PASI 100 and animprovement in the quality of life in a subject having psoriasiscomprising administering a TNFα inhibitor, e.g., human TNFα antibody, orantigen-binding portion thereof, to the to subject such that a PAS100score and DLQI score of 0 or 1 is achieved.

In one aspect, the invention provides a method of achieving a clinicalresponse in psoriasis in a subject comprising administering an effectiveamount of a TNFα inhibitor, e.g., a human TNFα antibody, orantigen-binding portion thereof, to the subject such that a clinicalresponse in psoriasis is achieved, wherein the effective TNFα inhibitorwas previously identified as achieving a PASI 75 response in at leastabout 77% of a patient population having psoriasis.

In one aspect, the invention provides a method of decreasing a DLQIscore of a subject having psoriasis by at least about 10 pointscomprising administering a TNFα inhibitor, e.g., a human TNFα antibodyto the subject, such that the DLQI score is decreased by at least about10 points.

In one aspect, the invention provides a method of decreasing a DLQIscore of a subject having psoriasis from a large/extremely large scoreto a no or small impact score comprising administering a TNFα inhibitor,e.g., human TNFα antibody to the subject, such that the DLQI score isdecreased from the large/extremely large score to the no or small impactscore.

In another aspect, the invention provides a method of decreasing a DLQIscore of a subject having psoriasis by at least about 10 pointscomprising administering a TNFα inhibitor, e.g., a human TNFα antibodyto the subject, such that the DLQI score is decreased by at least about10 points.

In one aspect, the invention provides a method of decreasing a PASIscore of a subject having psoriasis by at least about 8 pointscomprising administering a TNFα inhibitor, e.g., a human TNFα antibodyto the subject, such that the PASI score is decreased by at least about8 points.

In one aspect, the invention provides a method of decreasing a PGA scoreof a subject having psoriasis by at least about 2 points comprisingadministering a TNFα inhibitor, e.g., a human TNFα antibody to thesubject, such that the PGA score is decreased by at least about 2points.

In one embodiment, the TNFα inhibitor, e.g., human TNFα antibody, orantigen-binding portion thereof, is administered to the subject on amultiple variable dosing regimen.

In one embodiment, the TNFα inhibitor, e.g., human TNFα antibody, orantigen-binding portion thereof, is administered to the subject on abiweekly dosing regimen, including at a dose of about 40 mg.

In yet another embodiment, the TNFα inhibitor, e.g., a human TNFαantibody, or antigen-binding portion thereof, is administered to thesubject via subcutaneous administration.

In another aspect, the invention further provides a method of treatingpsoriasis in a subject comprising administering an initial loading doseof a TNFα inhibitor, e.g., a human TNFα antibody or antigen-bindingportion thereof, to the subject at week 0, administering a second dose,e.g., maintenance or treatment dose, of the TNFα inhibitor, to thesubject, wherein the second dose is about half the dose amount of theloading dose.

In one embodiment, the initial dose is given in its entirety on one dayor is divided over 2 days. In one embodiment, the second dose, e.g.,maintenance or treatment dose, is administered to the subject about oneweek after the first dose on a biweekly dosing regimen.

The invention also provides a means for determining the efficacy of aTNFα inhibitor, e.g., a human TNFα antibody or antigen-binding portionthereof, for the treatment of psoriasis. The invention includes a methodfor determining the efficacy of a TNFα inhibitor, e.g., human TNFαantibody, or an antigen-binding portion thereof, for improving thefunctional limitations of a subject having psoriasis comprisingdetermining an improvement in a DLQI score from a patient population whowas administered the TNFα inhibitor, wherein a DLQI score of no or smallimpact in at least about 67% of the patient population indicates thatthe TNFα inhibitor is an effective TNFα inhibitor for improving thefunctional limitations of a subject having psoriasis. In one embodiment,the subject has a baseline PASI score greater than or equal to 10 and abaseline DLQI score greater than about 10

The invention further provides a method of determining the efficacy of aTNFα inhibitor, e.g., a human TNFα antibody, or an antigen-bindingportion thereof, for treating psoriasis in a subject comprisingdetermining a Psoriasis Area Severity Index (PASI) 75 response of apatient population having psoriasis who was administered the TNFαinhibitor wherein a PASI 75 response achieved in at least about 62% ofthe patient population indicates that the TNFα inhibitor is an effectiveTNFα inhibitorfor the treatment of psoriasis in a subject. In oneembodiment, a PASI 75 response is achieved in at least about 70% of thepatient population indicates that the TNFα inhibitor is an effectivehuman TNFα antibody, or antigen-binding portion thereof, for thetreatment of psoriasis in a subject. In another embodiment, a PASI 75response is achieved in at least about 75% of the patient populationindicates that the TNFα inhibitor is an effective human TNFα antibody,or antigen-binding portion thereof, for the treatment of psoriasis in asubject. In still another embodiment, a PASI 75 response is achieved inat least about 80% of the patient population indicates that the TNFαinhibitor is an effective TNFα inhibitor for the treatment of psoriasisin a subject.

The invention also includes a method of determining the efficacy of aTNFα inhibitor, e.g., human TNFα antibody, or an antigen-binding portionthereof, for treating to psoriasis in a subject comprising determining aPsoriasis Area Severity Index (PASI) 90 response of a patient populationhaving psoriasis who was administered the TNFα inhibitor, wherein a PASI90 response achieved in at least about 48% of the patient populationindicates that the TNFα inhibitor, is an effective TNFα inhibitor fortreating psoriasis in a subject. In one embodiment, a PASI 90 responseachieved in at least about 52% of the patient population indicates thatthe TNFα inhibitor is an effective TNFα inhibitor, e.g., human TNFαantibody, or antigen-binding portion thereof, for treating psoriasis ina subject. In another embodiment, a PASI 90 response is achieved in atleast about 61% of the patient population indicates that the TNFαinhibitor is an effective TNFα inhibitor for treating psoriasis in asubject.

The invention also provides a method of treating psoriasis in a subjectcomprising administering an effective amount of a TNFα inhibitor, e.g.,human TNFα antibody, or antigen-binding portion thereof, to the subject,wherein the effective amount of the TNFα inhibitor was previouslyidentified as achieving a PASI 90 response in at least about 48% of apatient population having psoriasis.

The invention includes a method of determining the efficacy of a TNFαinhibitor, e.g., a human TNFα antibody, or antigen-binding portionthereof, for treating psoriasis in a subject comprising determining aPsoriasis Area Severity Index (PASI) 100 response of a patientpopulation having psoriasis and who was administered the TNFα inhibitorwherein a PASI 100 response is achieved in at least about 11% of thepatient population indicates that the TNFα inhibitor is an effectiveTNFα inhibitor for treating psoriasis in a subject. In one embodiment, aPASI 100 response is achieved in at least about 20% of the patientpopulation indicates that the TNFα inhibitor is an effective TNFαinhibitor for treating psoriasis in a subject. In another embodiment, aPASI 100 response is achieved in at least about 22% of the patientpopulation indicates that the TNFα inhibitor is an effective TNFαinhibitor for treating psoriasis in a subject.

The invention further provides a method of determining the efficacy of aTNFα inhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, to treat psoriasis in a subject comprising determining aPhysician's Global Assessment (PGA) score of a patient population havingpsoriasis who was administered the TNFα inhibitor, wherein a PGA scoreof “clear” or “almost clear” in at least about 27% of the patientpopulation indicates that the TNFα inhibitor is an effective TNFαinhibitor for treating psoriasis in a subject. In one embodiment, a PGAscore of “clear” or “almost clear” in at least about 48% of the patientpopulation indicates that the TNFα inhibitor is an effective TNFαinhibitor for treating psoriasis in a subject. In another embodiment, aPGA score of “clear” or “almost clear” in at least about 65% of thepatient population indicates that the TNFα inhibitor is an effectiveTNFα inhibitor for treating psoriasis in a subject. The inventionincludes a method for determining the efficacy of a TNFα inhibitor,e.g., human TNFα antibody, or antigen-binding portion thereof, forimproving the functional limitations of human subjects having moderateto severe psoriasis comprising administering the TNFα inhibitor to apreselected patient population having moderate to severe psoriasis; anddetermining the efficacy of the TNFα inhibitor sing a baselineDermatology Life Quality Index (DLQI) score from the patient populationand a DLQI score from a time period following administration of the TNFαinhibitor, herein a DLQI score of no or small impact in at least about83% of the patient population indicates that TNFα inhibitor isefficacious for improving the functional limitations of human subjectshaving moderate to psoriasis.

The efficacy of a TNFα inhibitor, e.g., human TNFα antibody, orantigen-binding portion thereof, for treating psoriasis in a patientpopulation, e.g., PASI 75 response (also referred to herein as aPASI/PASI75 score), may be evaluated by determining the percentage ofthe patient population for whom the TNFα inhibitor has been effectivefor treating psoriasis.

The invention also includes a method for determining the efficacy of aTNFα inhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, for treatment of psoriasis in a subject having a PASI of ≧10and a DLQI >10 comprising determining the efficacy of the TNFα inhibitorin a patient population having a PASI of ≧10 and a DLQI >10, using abaseline PASI score of the patient population before administration ofthe TNFα inhibitor and a PASI score following administration of the TNFαinhibitor, wherein a PASI75 response in at least about 44% of thepatient population following administration of the TNFα inhibitorindicates that the TNFα inhibitor is efficacious for treatment ofpsoriasis in a subject having a PASI ≧10 and a DLQI >10.

The invention further provides a method for determining the efficacy ofa TNFα inhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, for treatment of psoriasis in a subject having a PASI of ≧10and a DLQI >10 comprising determining the efficacy of the TNFα inhibitorin a patient population having a PASI of ≧10 and a DLQI >10, using abaseline PGA score of the patient population before administration ofthe TNFα inhibitor and a PGA score following administration of the TNFαinhibitor, wherein a PGA score of “clear” or “almost clear” in at leastabout 33% of the patient population following administration of the TNFαinhibitor indicates that the TNFα inhibitor is efficacious for treatmentof psoriasis in a subject having a PASI ≧10 and a DLQI >10.

The invention describes a method for determining the efficacy of a TNFαinhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, for treatment of psoriasis in a subject having a PASI of ≧10and a DLQI >10 comprising determining the efficacy of the TNFα inhibitorin a patient population having a PASI of ≧10 and a to DLQI >10, using abaseline DLQI score of the patient population before administration ofthe TNFα inhibitor and a DLQI score following administration of the TNFαinhibitor, wherein a decrease in the DLQI score of at least about 12indicates that the TNFα inhibitor is efficacious for treatment ofpsoriasis in a subject having a PASI ≧10 and a DLQI >10.

The invention further provides a method for determining the efficacy ofa TNFα inhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, for improving the general health of human subjects havingmoderate to severe psoriasis comprising administering the TNFα inhibitorto a preselected patient population having moderate to severe chronicplaque psoriasis; and determining the efficacy of the TNFα inhibitorusing a baseline SF-36 (Short Form 36 Health Survey) score from thepatient population and an SF-36 score from a time period followingadministration of the TNFα inhibitor, wherein an improvement in theSF-36 score indicates that TNFα inhibitor is efficacious for improvingthe functional limitations of human subjects having moderate to severepsoriasis. The change in the SF-36 score may be selected from any of theeight domains of the SF-36 instrument, including physical function,physical role limitations, vitality, general health perceptions, bodilypain, social function, emotional role limitations, and mental health. Inone embodiment, an improvement of at least 16 in the bodily pain domainindicates that the TNFα inhibitor is efficacious for treatment ofmoderate to severe chronic plaque psoriasis. The invention furtherprovides a method of improving an SF-36 score of a patient havingmoderate to severe chronic plaque psoriasis comprising administering tothe patient a TNFα inhibitor.

In one embodiment, the invention provides a method of determining theefficacy of a TNFα inhibitor, e.g., human TNFα antibody, orantigen-binding portion thereof, for treating psoriasis in a subjectcomprising determining a Psoriasis Area Severity Index (PASI) score of apatient population having psoriasis and who was administered the

TNFα inhibitor, wherein a PASI 75 response is achieved in at least about32% of the patient population indicates that the TNFα inhibitor is aneffective TNFα inhibitor for the treatment of psoriasis in a subject. Inone embodiment, the method further comprises administering the effectiveTNFα inhibitor to a subject to treat psoriasis. The invention provides amethod of treating psoriasis in a subject comprising administering aneffective amount of a TNFα inhibitor to the subject such that treatmentof psoriasis is maintained, wherein the effective human TNFα antibodywas previously identified as achieving a PASI 75 response in at leastabout 32% of a patient population having psoriasis.

In one embodiment, the invention provides a method of treating psoriasisin a subject comprising administering an effective amount of a TNFαinhibitor, e.g., a human TNFα antibody to the subject such thatpsoriasis is treated, wherein the effective to TNFα inhibitor waspreviously identified as achieving a PASI 75 response in at least about32% of a patient population having psoriasis.

In one embodiment, a PASI 75 response is achieved in at least about 32%of the patient population indicates that the TNFα inhibitor, e.g., ahuman TNFα antibody is an effective TNFα inhibitor for the treatment ofpsoriasis in a subject. In one embodiment, a PASI 75 response isachieved in at least about 40% of the patient population indicates thatthe TNFα inhibitor is an effective TNFα inhibitor for the treatment ofpsoriasis in a subject. In one embodiment, a PASI 75 response isachieved in at least about 50% of the patient population indicates thatthe TNFα inhibitor is an effective TNFα inhibitor for the treatment ofpsoriasis in a subject. In one embodiment, a PASI 75 response isachieved in at least about 60% of the patient population indicates thatthe TNFα inhibitor is an effective TNFα inhibitor for the treatment ofpsoriasis in a subject. In one embodiment, a PASI 75 response isachieved in at least about 70% of the patient population indicates thatthe TNFα inhibitor is an effective human TNFα antibody for the treatmentof psoriasis in a subject.

Numbers intermediate to the above recited percentages, e.g., 32%, 33%,34%.

35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%,49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%, 57%, 58%, 59%, 60%, 61%, 62%,63%, 64%, 65%, 66%, 67%, 68%, 69%, 70%, 71%, 72%, 73%, 74%, 75%, 76%,77%, 78%, 79%, 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, and 89%, aswell as all other numbers recited herein, are also intended to be partof this invention. Ranges of values using a combination of any of theabove recited values as upper and/or lower limits are intended to beincluded in the scope of the invention. For example, in one embodiment aPASI 75 response score of in at least between 32% and 90% of the patientpopulation indicates that the TNFα inhibitor is an effective TNFαinhibitor for the treatment of psoriasis in a subject.

In one embodiment the invention provides a method of determining theefficacy of a TNFα inhibitor for achieving a clinical response inpsoriasis in a subject comprising determining a PASI 90 response of apatient population having psoriasis and who was administered the humanTNFα antibody, wherein a PASI 90 response is achieved in at least about24% of the patient population indicates that the human TNFα antibody isan effective human TNFα antibody for achieving a clinical response inpsoriasis in a subject.

In one embodiment, the invention provides a method for achieving aclinical response in psoriasis in a subject comprising administering aneffective amount of a TNFα inhibitor, e.g., a human TNFα antibody, orantigen binding portion thereof, to the subject such that a clinicalresponse in psoriasis is achieved, wherein the effective amount of theTNFα inhibitor was previously identified as achieving a PASI 90 toresponse in at least about 24% of a patient population having psoriasisand a baseline PASI <10.

In one embodiment, a PASI 90 response is achieved in at least about 25%of the patient population indicates that the TNFα inhibito, e.g., humanTNFα antibody is an effective TNFα inhibitor for achieving a clinicalresponse in psoriasis in a subject. In one embodiment, a PASI 90response is achieved in at least about 30% of the patient populationindicates that the TNFα inhibitor is an effective TNFα inhibitor forachieving a clinical response in psoriasis in a subject. In oneembodiment, a PASI 90 response is achieved in at least about 40% of thepatient population indicates that the TNFα inhibitor is an effectiveTNFα inhibitor for achieving a clinical response in psoriasis in asubject. In one embodiment, a PASI 90 response is achieved in at leastabout 50% of the patient population indicates that the TNFα inhibitor isan effective TNFα inhibitor for achieving a clinical response inpsoriasis in a subject. In one embodiment, a PASI 90 response isachieved in at least about 60% of the patient population indicates thatthe TNFα inhibitor is an effective TNFα inhibitor for achieving aclinical response in psoriasis in a subject. In one embodiment, a PASI90 response is achieved in at least about 62% of the patient populationindicates that the TNFα inhibitor is an effective TNFα inhibitor forachieving a clinical response in psoriasis in a subject.

Numbers intermediate to the above recited percentages, e.g., 24%, 25%,26%, 27%, 28%, 29%, 30%, 31%, 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%,40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53%,54%, 55%, 56%, 57%, 58%, 59%, 60%, and 61%, as well as all other numbersrecited herein, are also intended to be part of this invention. Rangesof values using a combination of any of the above recited values asupper and/or lower limits are intended to be included in the scope ofthe invention. For example, in one embodiment a PASI 90 response scoreof in at least between 24% and 62% of the patient population indicatesthat the TNFα inhibitor is an effective TNFα inhibitor for the treatmentof psoriasis in a subject.

In one embodiment the invention provides a method of determining theefficacy of a TNFα inhibitor, e.g., human TNFα antibody, or antigenbinding portion thereof, for achieving a clinical response in psoriasisin a subject comprising determining a PASI 100 response of a patientpopulation having psoriasis and who was administered the TNFα inhibitor,wherein a PASI 100 response is achieved in at least about 11% of thepatient population indicates that the TNFα inhibitor is an effectiveTNFα inhibitor for achieving a clinical response in psoriasis in asubject.

In one embodiment, a PASI 100 response is achieved in at least about 15%of the patient population indicates that the TNFα inhibitor, e.g., ahuman TNFα antibody, is an to effective TNFα inhibitor for achieving aclinical response in psoriasis in a subject. In one embodiment, a PASI100 response is achieved in at least about 20% of the patient populationindicates that the TNFα inhibitor is an effective TNFα inhibitor forachieving a clinical response in psoriasis in a subject. In oneembodiment, a PASI 100 response is achieved in at least about 25% of thepatient population indicates that the TNFα inhibitor is an effectiveTNFα inhibitor for achieving a clinical response in psoriasis in asubject. In one embodiment, a PASI 100 response is achieved in at leastabout 30% of the patient population indicates that the TNFα inhibitor isan effective TNFα inhibitor for achieving a clinical response inpsoriasis in a subject. In one embodiment, a PASI 100 response isachieved in at least about 35% of the patient population indicates thatthe TNFα inhibitor is an effective TNFα inhibitor for achieving aclinical response in psoriasis in a subject.

Numbers intermediate to the above recited percentages, e.g., 15%, 16%,17%, 18%, 19%, 20%, 21%, 22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%,31%, 32%, 33%, and 34% as well as all other numbers recited herein, arealso intended to be part of this invention. Ranges of values using acombination of any of the above recited values as upper and/or lowerlimits are intended to be included in the scope of the invention. Forexample, in one embodiment a PASI 100 response score of in at leastbetween 15% and 35% of the patient population indicates that the TNFαinhibitor is an effective TNFα inhibitor for the treatment of psoriasisin a subject.

In one embodiment the invention provides a method of determining theefficacy of a TNFα inhibitor, e.g., a human TNFα antibody, for achievinga clinical response in psoriasis in a subject comprising determining aPhysician's Global Assessment (PGA) score of a patient population havingpsoriasis who was administered the TNFα inhibitor, wherein a PGA scoreof “clear” or “almost clear” in at least about 45% of the patientpopulation indicates that the TNFα inhibitor is an effective TNFαinhibitor for treating psoriasis in a subject.

In one embodiment, the invention provides a method of treating psoriasisin a subject comprising administering an effective amount of a TNFαinhibitor, e.g., a human TNFα antibody, to the subject, wherein theeffective TNFα inhibitor was previously identified as maintaining a PGAscore of “clear” or “almost clear” in at least about 48% of a patientpopulation having psoriasis.

In one embodiment, a PGA score of “clear” or “almost clear” in at leastabout 45% of a patient population having psoriasis indicates that theTNFα inhibitor, e.g., a human TNFα antibody, is an effective TNFαinhibitor for treating psoriasis in a subject. In one embodiment, a PGAscore of “clear” or “almost clear” in at least about 65% of a patientpopulation having psoriasis indicates that the TNFα inhibitor is aneffective TNFα inhibitor for treating psoriasis in a subject.

Numbers intermediate to the above recited percentages, e.g., 46%, 47%,48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%, 57%, 58%, 59%, 60%, 61%,62%, 63%, 64%, 65%, 66%, 67%, 68%, 69%, 70%, 71%, 72%, 73%, 74%, and75%, as well as all other numbers recited herein, are also intended tobe part of this invention. Ranges of values using a combination of anyof the above recited values as upper and/or lower limits are intended tobe included in the scope of the invention. For example, in oneembodiment a PGA score of “clear” or “almost clear” in at least between45% and 76% of the patient population indicates that the TNFα inhibitor,e.g., a human TNFα antibody, is an effective TNFα inhibitor for thetreatment of psoriasis in a subject.

The invention also includes further comprises administering an effectiveTNFα inhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, to a subject or patient population having psoriasis.

In one embodiment, the TNFα inhibitor, e.g., human TNFα antibody, orantigen-binding portion thereof, was administered to the patientpopulation or subject on a biweekly dosing regimen.

In still another embodiment, the TNFα inhibitor, e.g., a human TNFαantibody, is administered in a multiple variable dose regimen. In oneembodiment, the multiple variable dose regimen comprises an inductiondose which is at least double the treatment or maintenance dose. Inanother embodiment, the TNFα inhibitor is administered biweekly to thepatient population or subject. In one embodiment, the induction dosecomprises about 80 mg. In one embodiment, the treatment dose comprisesabout 40 mg.

In one embodiment, the TNFα inhibitor, e.g., human TNFα antibody, orantigen-binding portion thereof, was administered to the patientpopulation or subject at a dose of about 40 mg on a biweekly dosingregimen.

In another embodiment, the TNFα inhibitor, e.g., human TNFα antibody, orantigen-binding portion thereof, was administered to the patientpopulation or subject via subcutaneous administration.

The invention also provides an article of manufacture comprising a TNFαinhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, and a label or package insert, wherein the label or packageinsert indicates that aminosalicylates, corticosteroids, and/or animmunomodulatory agent, e.g., 6-mercaptopurine and azathioprine, may becontinued during treatment with the TNFα inhibitor, e.g., human TNFαantibody, or antigen-binding portion thereof, for psoriasis.

The invention includes an article of manufacture comprising a TNFαinhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, and a label or package insert indicating that a history ofsystemic or biologic therapy does not adversely effect to efficacy ofthe TNFα inhibitor, e.g., human TNFα antibody or antigen-binding portionthereof, in patients for the treatment of psoriasis and/or thatadministration of the TNFα inhibitor is safe in patients with a historyof systemic or biologic therapy.

The invention further provides an article of manufacture comprising aTNFα inhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, and a label or package insert indicating that use of TNFblockers has been associated with reactivation of hepatitis B virus(HBV) in patients who are chronic carriers of the virus.

The invention provides an article of manufacture comprising: a TNFαinhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, and a label or package insert contained within the packagingmaterial indicating that an adverse event which has been reported in theuse of the TNFα inhibitor, e.g., human TNFα antibody is angioneuroticedema.

The invention also includes an article of manufacture comprising a TNFαinhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, and a label or package insert indicating that the TNFαinhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, may be used as a first line treatment for the treatment ofpsoriasis.

Also included in the invention is an article of manufacture comprising aTNFα inhibitor, e.g.,human TNFα antibody, or antigen-binding portionthereof, and a label or package insert indicating that the TNFαinhibitor, e.g., human TNFα antibody, or antigen-binding portionthereof, may be used for the treatment of psoriasis withoutmethotrexate.

Further included in the invention is an article of manufacturecomprising a TNFα inhibitor, e.g., human TNFα antibody, orantigen-binding portion thereof, and a label or package insertindicating that the TNFα inhibitor, e.g., human TNFα antibody, orantigen-binding portion thereof, was found to be more effective thanmethotrexate as a first line treatment and/or that the TNFα inhibitor,e.g., human TNFα antibody, or antigen-binding portion thereof, hassignificantly superior efficacy for the treatment of moderate to severepsoriasis versus methotrexate.

The invention includes a package comprising a TNFα inhibitor, e.g.,human TNFα antibody, or antigen-binding portion thereof, andinstructions for administering the TNFα inhibitor to a human subject forthe treatment of adults with psoriasis, e.g., moderate to severepsoriasis, who have had an inadequate response to conventional therapy.The invention also includes a package comprising a TNFα inhibitor, e.g.,human TNFα antibody, or antigen-binding portion thereof, wherein thepackage contains, on the label and in a position which is visible to asubject, including a prospective purchaser, a printed statement whichinforms a subject, including a prospective purchaser, that the TNFαinhibitor is indicated for the treatment of adults to with moderate tosevere psoriasis who have had an inadequate response to conventionaltherapy.

The invention further provides a package comprising a TNFα inhibitor,e.g., human TNFα antibody, or antigen-binding portion thereof, whereinthe package contains, on the label and in a position which is visible toa subject, including a prospective purchaser, a printed statement whichinforms a subject, including a prospective purchaser, that therecommended dose of the TNFα inhibitor for patients with psoriasis is 40mg TNFα inhibitor administered every other week as a single dose viasubcutaneous injection.

The invention also provides a package comprising a TNFα inhibitor, e.g.,human TNFα antibody, or antigen-binding portion thereof, wherein thepackage contains, on the label and in a position which is visible to asubject, including a prospective purchaser, a printed statement whichinforms prospective purchasers that the TNFα inhibitor has been shown tohave an uncommon undesirable effect in clinical studies. Examples ofsuch effects are provided in the examples section described herein.

The invention provides an article of manufacture comprising: a packagingmaterial; a TNFα inhibitor, e.g., human TNFα antibody, orantigen-binding portion thereof, and a label or package insert containedwithin the packaging material indicating that a history of systemic orbiologic therapy does not adversely effect efficacy of the TNFαinhibitor in patients.

In one aspect, the invention provides an article of manufacturecomprising a TNFα inhibitor, e.g., human TNFα antibody and a packageinsert, wherein the package insert indicates the recommended TNFαinhibitor, e.g., human TNFα antibody, dose regimen for adult patientswith psoriasis is 80 mg at week 0, 80 mg at week 1, followed by 40 mgevery other week beginning at week 3.

In one aspect, the invention provides an article of manufacturecomprising a

TNFα inhibitor, e.g., human TNFα antibody and a package insert, whereinthe package insert indicates the recommended TNFα inhibitor, e.g., humanTNFα antibody, dose regimen for adult patients with psoriasis is 80 mgat week 0, 40 mg at week 1, followed by 40 mg every other week beginningat week 3.

In one aspect, the invention provides an article of manufacture whichcomprising adalimumab and a package insert, wherein the package insertindicates that the adalimumab may be used to treat psoriasis in patientswho have had an inadequate response to conventional therapy and/or whohave lost response to or are intolerant to infliximab.

In one aspect, the invention provides an article of manufacturecomprising: a) a packaging material; b) a human TNFα antibody, and c) alabel or package insert to contained within the packaging materialindicating that the human TNFα antibody may be used as a first linetreatment for the treatment of psoriasis.

In one aspect, the invention provides an article of manufacturecomprising: a) a packaging material; b) a human TNFα antibody, and c) alabel or package insert contained within the packaging materialindicating that the human TNFα antibody may be used for the treatment ofpsoriasis without methotrexate.

In another aspect, the invention provides an article of manufacturecomprising: a) a packaging material; b) a human TNFα antibody, and c) alabel or package insert contained within the packaging materialindicating that the human TNFα antibody was found to be more effectivethan methotrexate as a first line treatment and/or that the human TNFαantibody has significantly superior efficacy for the treatment ofmoderate to severe psoriasis versus methotrexate.

In one embodiment, the TNFα inhibitor is selected from the groupconsisting of an anti-TNFα antibody, or an antigen-binding portionthereof, a TNF fusion protein, or a recombinant TNF binding protein.

In one embodiment, the TNF fusion protein is etanercept.

In one embodiment, the TNFα antibody, or antigen-binding portionthereof, is selected from the group consisting of a chimeric antibody, ahumanized antibody, and a multivalent antibody.

In one embodiment of the invention, the TNFα antibody, orantigen-binding portion thereof, is a human antibody.

In another embodiment, the TNFα antibody, or antigen-binding portionthereof, is an isolated human antibody that dissociates from human TNFαwith a K_(d) of 1×10⁻⁸ M or less and a K_(off) rate constant of1×10⁻³s⁻¹ or less, both determined by surface plasmon resonance, andneutralizes human TNFα cytotoxicity in a standard in vitro L929 assaywith an IC₅₀ of 1×10⁻⁷ M or less.

In one embodiment of the invention, the TNFα antibody is an isolatedhuman antibody, or antigen-binding portion thereof, with the followingcharacteristics:

a) dissociates from human TNFα with a K_(off) rate constant of 1×10⁻³s⁻¹or less, as determined by surface plasmon resonance;

b) has a light chain CDR3 domain comprising the amino acid sequence ofSEQ ID NO: 3, or modified from SEQ ID NO: 3 by a single alaninesubstitution at position 1, 4, 5, 7 or 8 or by one to five conservativeamino acid substitutions at positions 1, 3, 4, 6, 7, 8 and/or 9;

c) has a heavy chain CDR3 domain comprising the amino acid sequence ofSEQ ID NO: 4, or modified from SEQ ID NO: 4 by a single alaninesubstitution at position 2, 3, 4, 5, 6, 8, 9, 10 or 11 or by one to fiveconservative amino acid to substitutions at positions 2, 3, 4, 5, 6, 8,9, 10, 11 and/or 12.

In one embodiment of the invention, the TNFα antibody is an isolatedhuman antibody, or an antigen binding portion thereof, with a lightchain variable region (LCVR) comprising the amino acid sequence of SEQID NO: 1 and a heavy chain variable region (HCVR) comprising the aminoacid sequence of SEQ ID NO: 2.

In one embodiment, the TNFα antibody, or antigen-binding portionthereof, is adalimumab.

In one embodiment, the TNFα antibody, or antigen-binding portionthereof, is a 40 mg dose.

In another embodiment, the TNFα antibody, or antigen-binding portionthereof, is administered subcutaneously.

The another embodiment of the invention, the anti- TNFα antibody, orantigen-binding portion thereof, is infliximab or golimumab.

In one embodiment, the psoriasis is moderate to severe psoriasis. Inanother embodiment, the moderate to severe psoriasis is moderate tosevere chronic plaque psoriasis.

In one embodiment, the TNFα inhibitor is administered weekly to thepatient population or subject having psoriasis. In another embodiment,TNFα inhibitor is administered biweekly to the patient population orsubject having psoriasis.

In one embodiment, the multiple variable dose regimen comprises aninduction dose which is at least double the treatment dose. In oneembodiment, the induction dose comprises about 80 mg. In one embodiment,the treatment dose comprises about 40 mg.

In one embodiment, the patient population or subject also has psoriaticarthritis.

In one embodiment, the patient population or subject has a PASI score,e.g., a baseline score, of ≧10 and a DLQI score e.g., a baseline score,>10.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows the study design from Phase II clinical trial.

FIG. 2 shows the PASI improvement in patients after dosage escalation.

FIG. 3 shows the study design for the Phase III trial described inExample 9.

FIG. 4 shows a graph describing mean percentage PASI improvement

FIG. 5 describes the study design described in Example 10, which is aPhase III study off of a Phase II study.

FIG. 6 graphically depicts the mean percentage PASI improvement throughweek 60.

FIG. 7 describes the study design of the Phase III study described inExample 11.

FIG. 8 describes the study design of Example 12.

FIG. 9 describes patient disposition for Example 12.

FIG. 10 describes the mean percentage PASI improvement through week 60of the Phase II trial.

FIG. 11 is a flow chart depicting the disposition and assessment ofpatients with plaque psoriasis who were non-responders to high doseentanercept.

FIG. 12 is a graph depicting the Psoriasis Area and Severity Indexscores (PASI) for patients treated with adalimumab.

FIG. 13 is a graph depicting the Dermatology Life Quality Index (DLQI)for patients treated with adalimumab.

DETAILED DESCRIPTION OF THE INVENTION I. Definitions

The term “human TNFα” (abbreviated herein as hTNFα, or simply hTNF), asused herein, is intended to refer to a human cytokine that exists as a17 kD secreted form and a 26 kD membrane associated form, thebiologically active form of which is composed of a trimer ofnoncovalently bound 17 kD molecules. The structure of hTNFα is describedfurther in, for example, Pennica, D., et al. (1984) Nature 312:724-729;Davis, J. M., et al. (1987) Biochemistry 26:1322-1326; and Jones, E. Y.,et al. (1989) Nature 338:225-228. The term human TNFα is intended toinclude recombinant human TNFα (rhTNFα), which can be prepared bystandard recombinant expression methods or purchased commercially (R & DSystems, Catalog No. 210-TA, Minneapolis, Minn.). TNFα is also referredto as TNF.

The term “TNFα inhibitor” includes agents which interfere with TNFαactivity. The term also includes each of the anti-TNFα human antibodiesand antibody portions described herein as well as those described inU.S. Pat. Nos. 6,090,382; 6,258,562; 6,509,015, and in U.S. patentapplication Ser. Nos. 09/801185 and 10/302356. In one embodiment, theTNFα inhibitor used in the invention is an anti-TNFα antibody, or afragment thereof, including infliximab (Remicade®, Johnson and Johnson;described in U.S. Pat. No. 5,656,272, incorporated by reference herein),CDP571 (a humanized monoclonal anti-TNF-alpha IgG4 antibody), CDP 870 (ahumanized monoclonal anti-TNF-alpha antibody fragment), an anti-TNF dAb(Peptech), CNTO 148 (golimumab; Medarex and Centocor, see WO 02/12502and U.S. Pat. No.7,521,206 and U.S. Pat. No. 7,250,165, incorporated byreference herein), and adalimumab (HUMIRA®^(®) Abbott Laboratories, ahuman anti-TNF mAb, described in U.S. Pat. No. 6,090,382 as D2E7,incorporated by reference herein). Additional TNFα antibodies which maybe used in the invention are described in U.S. Pat. Nos. 6,593,458;6,498,237; 6,451,983; and 6,448,380, each of which is incorporated byreference herein. In another embodiment, the TNFα inhibitor is a TNFfusion protein, e.g., etanercept (Enbrel®, Amgen; described in WO91/03553 and WO 09/406476, incorporated by reference herein). In anotherembodiment, the TNFα inhibitor is a recombinant TNF binding protein(r-TBP-I) (Serono).

The term “antibody”, as used herein, is intended to refer toimmunoglobulin molecules comprised of four polypeptide chains, two heavy(H) chains and two light (L) chains inter-connected by disulfide bonds.Each heavy chain is comprised of a heavy chain variable region(abbreviated herein as HCVR or VH) and a heavy chain constant region.The heavy chain constant region is comprised of three domains, CH1, CH2and CH3. Each light chain is comprised of a light chain variable region(abbreviated herein as LCVR or VL) and a light chain constant region.The light chain constant region is comprised of one domain, CL. The VHand VL regions can be further subdivided into regions ofhypervariability, termed complementarity determining regions (CDR),interspersed with regions that are more conserved, termed frameworkregions (FR). Each VH and VL is composed of three CDRs and four FRs,arranged from amino-terminus to carboxy-terminus in the following order:FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. The antibodies of the inventionare described in further detail in U.S. Pat. Nos. 6,090,382; 6,258,562;and 6,509,015, each of which is incorporated herein by reference in itsentirety.

The term “antigen-binding portion” or “antigen-binding fragment” of anantibody (or simply “antibody portion”), as used herein, refers to oneor more fragments of an antibody that retain the ability to specificallybind to an antigen (e.g., hTNFα). It has been shown that theantigen-binding function of an antibody can be performed by fragments ofa full-length antibody. Binding fragments include Fab, Fab′, F(ab′)₂,Fabc, Fv, single chains, and single-chain antibodies. Examples ofbinding fragments encompassed within the term “antigen-binding portion”of an antibody include (i) a Fab fragment, a monovalent fragmentconsisting of the VL, VH, CL and CH1 domains; (ii) a F(ab′)₂ fragment, abivalent fragment comprising two Fab fragments linked by a disulfidebridge at the hinge region; (iii) a Fd fragment consisting of the VH andCH1 domains; (iv) a Fv fragment consisting of the VL and VH domains of asingle arm of an antibody, (v) a dAb fragment (Ward et al. (1989) Nature341:544-546), which consists of a VH domain; and (vi) an isolatedcomplementarity determining region (CDR). Furthermore, although the twodomains of the Fv fragment, VL and VH, are coded for by separate genes,they can be joined, using recombinant methods, by a synthetic linkerthat enables them to be made as a single protein chain in which the VLand VH regions pair to form monovalent molecules (known as single chainFv (scFv); see e.g., Bird et al. (1988) Science 242:423-426; and Hustonet al. (1988) Proc. Natl. Acad. Sci. USA 85:5879-5883) . Such singlechain antibodies are also intended to be encompassed within the term“antigen-binding portion” of an antibody. Other forms of single chainantibodies, such as diabodies are also encompassed. Diabodies arebivalent, bispecific to antibodies in which VH and VL domains areexpressed on a single polypeptide chain, but using a linker that is tooshort to allow for pairing between the two domains on the same chain,thereby forcing the domains to pair with complementary domains ofanother chain and creating two antigen binding sites (see e.g., Holligeret al. (1993) Proc. Natl. Acad. Sci. USA 90:6444-6448; Poljak et al.(1994) Structure 2:1121-1123). The antibody portions of the inventionare described in further detail in U.S. Pat. Nos. 6,090,382, 6,258,562,6,509,015, each of which is incorporated herein by reference in itsentirety.

Still further, an antibody or antigen-binding portion thereof may bepart of a larger immunoadhesion molecules, formed by covalent ornoncovalent association of the antibody or antibody portion with one ormore other proteins or peptides. Examples of such immunoadhesionmolecules include use of the streptavidin core region to make atetrameric scFv molecule (Kipriyanov, S. M., et al. (1995) HumanAntibodies and Hybridomas 6:93-101) and use of a cysteine residue, amarker peptide and a C-terminal polyhistidine tag to make bivalent andbiotinylated scFv molecules (Kipriyanov, S. M., et al. (1994) Mol.Immunol. 31:1047-1058). Antibody portions, such as Fab and F(ab′)₂fragments, can be prepared from whole antibodies using conventionaltechniques, such as papain or pepsin digestion, respectively, of wholeantibodies. Moreover, antibodies, antibody portions and immunoadhesionmolecules can be obtained using standard recombinant DNA techniques, asdescribed herein.

A “conservative amino acid substitution”, as used herein, is one inwhich one amino acid residue is replaced with another amino acid residuehaving a similar side chain. Families of amino acid residues havingsimilar side chains have been defined in the art, including basic sidechains (e.g., lysine, arginine, histidine), acidic side chains (e.g.,aspartic acid, glutamic acid), uncharged polar side chains (e.g.,glycine, asparagine, glutamine, serine, threonine, tyrosine, cysteine),nonpolar side chains (e.g., alanine, valine, leucine, isoleucine,proline, phenylalanine, methionine, tryptophan), beta-branched sidechains (e.g., threonine, valine, isoleucine) and aromatic side chains(e.g., tyrosine, phenylalanine, tryptophan, histidine).

“Chimeric antibodies” refers to antibodies wherein one portion of eachof the amino acid sequences of heavy and light chains is homologous tocorresponding sequences in antibodies derived from a particular speciesor belonging to a particular class, while the remaining segment of thechains is homologous to corresponding sequences from another species. Inone embodiment, the invention features a chimeric antibody orantigen-binding fragment, in which the variable regions of both lightand heavy chains mimics the variable regions of antibodies derived fromone species of mammals, while the constant portions are homologous tothe sequences in antibodies derived from another species. In a preferredembodiment of the invention, chimeric to antibodies are made by graftingCDRs from a mouse antibody onto the framework regions of a humanantibody.

“Humanized antibodies” refer to antibodies which comprise at least onechain comprising variable region framework residues substantially from ahuman antibody chain (referred to as the acceptor immunoglobulin orantibody) and at least one complementarity determining region (CDR)substantially from a non-human-antibody (e.g., mouse). In addition tothe grafting of the CDRs, humanized antibodies typically undergo furtheralterations in order to improve affinity and/or immmunogenicity.

The term “multivalent antibody” refers to an antibody comprising morethan one antigen recognition site. For example, a “bivalent” antibodyhas two antigen recognition sites, whereas a “tetravalent” antibody hasfour antigen recognition sites. The terms “monospecific”, “bispecific”,“trispecific”, “tetraspecific”, etc. refer to the number of differentantigen recognition site specificities (as opposed to the number ofantigen recognition sites) present in a multivalent antibody. Forexample, a “monospecific” antibody's antigen recognition sites all bindthe same epitope. A “bispecific” or “dual specific” antibody has atleast one antigen recognition site that binds a first epitope and atleast one antigen recognition site that binds a second epitope that isdifferent from the first epitope. A “multivalent monospecific” antibodyhas multiple antigen recognition sites that all bind the same epitope. A“multivalent bispecific” antibody has multiple antigen recognitionsites, some number of which bind a first epitope and some number ofwhich bind a second epitope that is different from the first epitope

The term “human antibody”, as used herein, is intended to includeantibodies having variable and constant regions derived from humangermline immunoglobulin sequences. The human antibodies of the inventionmay include amino acid residues not encoded by human germlineimmunoglobulin sequences (e.g., mutations introduced by random orsite-specific mutagenesis in vitro or by somatic mutation in vivo), forexample in the CDRs and in particular CDR3. However, the term “humanantibody”, as used herein, is not intended to include antibodies inwhich CDR sequences derived from the germline of another mammalianspecies, such as a mouse, have been grafted onto human frameworksequences.

The term “recombinant human antibody”, as used herein, is intended toinclude all human antibodies that are prepared, expressed, created orisolated by recombinant means, such as antibodies expressed using arecombinant expression vector transfected into a host cell (describedfurther below), antibodies isolated from a recombinant, combinatorialhuman antibody library (described further below), antibodies isolatedfrom an animal (e.g., a mouse) that is transgenic for humanimmunoglobulin genes (see e.g., Taylor et al. (1992) Nucl. Acids Res.20:6287) or antibodies prepared, expressed, created or isolated by anyother means that involves splicing of human immunoglobulin genesequences to other DNA sequences. Such recombinant human antibodies havevariable and constant regions derived from human germline immunoglobulinsequences. In certain embodiments, however, such recombinant humanantibodies are subjected to in vitro mutagenesis (or, when an animaltransgenic for human Ig sequences is used, in vivo somatic mutagenesis)and thus the amino acid sequences of the VH and VL regions of therecombinant antibodies are sequences that, while derived from andrelated to human germline VH and VL sequences, may not naturally existwithin the human antibody germline repertoire in vivo.

Such chimeric, humanized, human, and dual specific antibodies can beproduced by recombinant DNA techniques known in the art, for exampleusing methods described in PCT International Application No.PCT/US86/02269; European Patent Application No. 184,187; European PatentApplication No. 171,496; European Patent Application No. 173,494; PCTInternational Publication No. WO 86/01533; U.S. Pat. No. 4,816,567;European Patent Application No. 125,023; Better et al. (1988) Science240:1041-1043; Liu et al. (1987) Proc. Natl. Acad. Sci. USA84:3439-3443; Liu et al. (1987) J. Immunol. 139:3521-3526; Sun et al.(1987) Proc. Natl. Acad. Sci. USA 84:214-218; Nishimura et al. (1987)Cancer Res. 47:999-1005; Wood et al. (1985) Nature 314:446-449; Shaw etal. (1988) J. Natl. Cancer Inst. 80:1553-1559); Morrison (1985) Science229:1202-1207; Oi et al. (1986) BioTechniques 4:214; U.S. Pat. No.5,225,539; Jones et al. (1986) Nature 321:552-525; Verhoeyan et al.(1988) Science 239:1534; and Beidler et al. (1988) J. Immunol.141:4053-4060, Queen et al., Proc. Natl. Acad. Sci. USA 86:10029-10033(1989), U.S. Pat. No. 5,530,101, U.S. Pat. No. 5,585,089, U.S. Pat. No.5,693,761, U.S. Pat. No. 5,693,762, Selick et al., WO 90/07861, andWinter, U.S. Pat. No. 5,225,539.

An “isolated antibody”, as used herein, is intended to refer to anantibody that is substantially free of other antibodies having differentantigenic specificities (e.g., an isolated antibody that specificallybinds hTNFα is substantially free of antibodies that specifically_bindantigens other than hTNFα). An isolated antibody that specifically bindshTNFα may, however, have cross-reactivity to other antigens, such asTNFα molecules from other species. Moreover, an isolated antibody may besubstantially free of other cellular material and/or chemicals.

A “neutralizing antibody”, as used herein (or an “antibody thatneutralized hTNFα activity”), is intended to refer to an antibody whosebinding to hTNFα results in inhibition of the biological activity ofhTNFα. This inhibition of the biological activity of hTNFα can beassessed by measuring one or more indicators of hTNFα biologicalactivity, such as hTNFα-induced cytotoxicity (either in vitro or invivo), hTNFα-induced cellular activation and hTNFα binding to hTNFαreceptors. These indicators of hTNFα biological activity can be assessedby one or more of several standard in vitro or in vivo assays known inthe art (see U.S. Pat. No. 6,090,382). Preferably, the ability of anantibody to neutralize hTNFα activity is assessed by inhibition ofhTNFα-induced cytotoxicity of L929 cells. As an additional oralternative parameter of hTNFα activity, the ability of an antibody toinhibit hTNFα-induced expression of ELAM-1 on HUVEC, as a measure ofhTNFα-induced cellular activation, can be assessed. The term “surfaceplasmon resonance”, as used herein, refers to an optical phenomenon thatallows for the analysis of real-time biospecific interactions bydetection of alterations in protein concentrations within a biosensormatrix, for example using the BlAcore system (Pharmacia Biosensor AB,Uppsala, Sweden and Piscataway, N.J.). For further descriptions, seeExample 1 of U.S. Pat. No. 6,258,562 and Jonsson et al. (1993) Ann.Biol. Clin. 51:19; Jonsson et al. (1991) Biotechniques 11:620-627;Johnsson et al. (1995) J. Mol. Recognit. 8:125; and Johnnson et al.(1991) Anal.Biochem.198:268.

The term “K_(off)”, as used herein, is intended to refer to the off rateconstant for dissociation of an antibody from the antibody/antigencomplex.

The term “K_(d)”, as used herein, is intended to refer to thedissociation constant of a particular antibody-antigen interaction.

The term “IC₅₀” as used herein, is intended to refer to theconcentration of the inhibitor required to inhibit the biologicalendpoint of interest, e.g., neutralize cytotoxicity activity.

The term “biologic therapy” refers to a protein-based therapy. In oneembodiment, the biologic therapy is a TNFR: Fc fusion protein, such asetanercept.

The term “dose,” as used herein, refers to an amount of TNFα inhibitorwhich is administered to a subject.

The term “dosing”, as used herein, refers to the administration of asubstance (e.g., an anti-TNFα antibody) to achieve a therapeuticobjective (e.g., treatment of psoriasis).

A “dosing regimen” describes a treatment schedule for a TNFα inhibitor,e.g., a treatment schedule over a prolonged period of time and/orthroughout the course of treatment, e.g. administering a first dose of aTNFα inhibitor at week 0 followed by a second dose of a TNFα inhibitoron a biweekly dosing regimen.

The term “fixed dosing regimen” refers to a dosing regimen which relieson a fixed dose amount of an agent for the treatment of a disorder. In apreferred embodiment, the fixed dosing regimen includes administering afixed dose amount of a TNFα inhibitor, such as a human TNFα antibody,for the treatment of a skin disorder associated with detrimental TNFαactivity, such as psoriasis. A fixed dose refers to a pre-determinedamount of an agent, e.g., 20 mg, 21 mg, 22 mg, 23 mg, 24 mg, 25 mg, 40mg, 45 mg, 50 mg, 80 mg, 90 mg, 100 mg, etc. In one embodiment, a fixeddosing to regimen includes a dosing regimen where a TNFα inhibitor isadministered to a subject as a fixed dose consecutively for a given timeperiod, e.g., 4 weeks, 8 weeks, 16, weeks, 24 weeks, 26 weeks, 32 weeks,36 weeks, 42 weeks, 48 weeks, 52 weeks, 56 weeks, etc., beginning at theinitial dose. As used herein, a dose amount referred to by an amount inmg, e.g., 40 mg, is equivalent to a fixed dose. A fixed dose is notdependent on the weight of a subject.

The term “multiple-variable dose” includes different doses of a TNFαinhibitor which are administered to a subject for therapeutic treatment.“Multiple-variable dose regimen” or “multiple-variable dose therapy”describes a treatment schedule which is based on administering differentamounts of TNFα inhibitor at various time points throughout the courseof treatment. Multiple-variable dose regimens are described in PCTapplication no. PCT/US05/12007 and U.S. Pat. No. 20060009385, which isincorporated by reference herein.

The term “maintenance therapy” or “maintenance dosing regime” refers toa treatment schedule for a subject or patient diagnosed with adisorder/disease, e.g., psoriasis, to enable them to maintain theirhealth in a given state, e.g, remission. Generally, the first goal oftreatment of psoriasis is to induce remission in the subject in needthereof. The next challenge is to keep the subject in remission.Maintenance doses may be used in a maintenance therapy for maintainingremission in a subject who has achieved remission of a disease or whohas reached a state of the disease which is advantageous, e.g. reductionin symptoms. In one embodiment, a maintenance therapy of the inventionis used for a subject or patient diagnosed with a disorder/disease,e.g., psoriasis to enable them to maintain their health in a state whichis completely free of symptoms associated with the disease. In oneembodiment, a maintenance therapy of the invention is used for a subjector patient diagnosed with a disorder/disease, e.g., psoriasis, to enablethem to maintain their health in a state which is substantially free ofsymptoms associated with the disease. In one embodiment, a maintenancetherapy of the invention is used for a subject or patient diagnosed witha disorder/disease, e.g., psroaisis, to enable them to maintain theirhealth in a state where there is a significant reduction in symptomsassociated with the disease.

The term “induction dose” or “loading dose,” used interchangeablyherein, refers to the first dose of TNFα inhibitor which is initiallyused to induce remission of psoriasis. Often, the loading dose is largerin comparison to the subsequent maintenance or treatment dose. Theinduction dose can be a single dose or, alternatively, a set of doses.In one embodiment, an induction dose is subsequently followed byadministration of smaller doses of TNFα inhibitor, e.g., the treatmentor maintenance dose. The induction dose is administered during theinduction or loading phase of therapy. In one embodiment of theinvention, the induction dose is at least twice the given amount of thetreatment dose. In one embodiment of the invention, the induction doseis 80 mg.

The term “treatment phase” or “maintenance phase”, as used herein,refers to a period of treatment comprising administration of a TNFαinhibitor to a subject in order to maintain a desired therapeuticeffect, i.e., maintaining remission of psoriasis.

The term “maintenance dose” or “treatment dose” is the amount of TNFαinhibitor taken by a subject to maintain or continue a desiredtherapeutic effect. A maintenance dose can be a single dose or,alternatively, a set of doses. A maintenance dose is administered duringthe treatment or maintenance phase of therapy. In one embodiment, amaintenance dose(s) is smaller than the induction dose(s). In oneembodiment, multiple maintenance doses can be equal to each other whenadministered in succession. In one embodiment, the invention provides amaintenance dose of 40 mg of a human TNFα antibody, or antigen-bindingportion thereof, e.g., adalimumab, administered subcutaneously to asubject who is in remission, every other week, or biweekly. In oneembodiment, the maintenance dose is administered every other weekbeginning at week 1 of treatment.

The terms “biweekly dosing regimen”, “biweekly dosing”, and “biweeklyadministration”, as used herein, refer to the time course ofadministering a substance (e.g., an anti-TNFα antibody) to a subject toachieve a therapeutic objective, e.g, throughout the course oftreatment. The biweekly dosing regimen is not intended to include aweekly dosing regimen. Preferably, the substance is administered every9-19 days, more preferably, every 11-17 days, even more preferably,every 13-15 days, and most preferably, every 14 days. In one embodiment,the biweekly dosing regimen is initiated in a subject at week 0 oftreatment. In another embodiment, a maintenance dose is administered ona biweekly dosing regimen. In one embodiment, both the loading andmaintenance doses are administered according to a biweekly dosingregimen. In one embodiment, biweekly dosing includes a dosing regimenwherein doses of a TNFα inhibitor are administered to a subject everyother week beginning at week 0. In one embodiment, biweekly dosingincludes a dosing regimen where doses of a TNFα inhibitor areadministered to a subject every other week consecutively for a giventime period, e.g., 4 weeks, 8 weeks, 16, weeks, 24 weeks, 26 weeks, 32weeks, 36 weeks, 42 weeks, 48 weeks, 52 weeks, 56 weeks, etc. Biweeklydosing methods are also described in U.S. Pat. No. 20030235585,incorporated by reference herein.

The term “combination” as in the phrase “a first agent in combinationwith a second agent” includes co-administration of a first agent and asecond agent, which for example may be dissolved or intermixed in thesame pharmaceutically acceptable carrier, or administration of a firstagent, followed by the second agent, or administration to of the secondagent, followed by the first agent. The present invention, therefore,includes methods of combination therapeutic treatment and combinationpharmaceutical compositions.

The term “concomitant” as in the phrase “concomitant therapeutictreatment” includes administering an agent in the presence of a secondagent. A concomitant therapeutic treatment method includes methods inwhich the first, second, third, or additional agents areco-administered. A concomitant therapeutic treatment method alsoincludes methods in which the first or additional agents areadministered in the presence of a second or additional agents, whereinthe second or additional agents, for example, may have been previouslyadministered. A concomitant therapeutic treatment method may be executedstep-wise by different actors. For example, one actor may administer toa subject a first agent and a second actor may to administer to thesubject a second agent, and the administering steps may be executed atthe same time, or nearly the same time, or at distant times, so long asthe first agent (and additional agents) are after administration in thepresence of the second agent (and additional agents). The actor and thesubject may be the same entity (e.g., human).

The term “combination therapy”, as used herein, refers to theadministration of two or more therapeutic substances, e.g., an anti-TNFαantibody and another drug. The other drug(s) may be administeredconcomitant with, prior to, or following the administration of ananti-TNFα antibody.

The term “treatment,” as used within the context of the presentinvention, is meant to include therapeutic treatment, as well asprophylactic or suppressive measures, for the treatment of psoriasis.For example, the term treatment may include administration of a TNFαinhibitor prior to or following the onset of psoriasis therebypreventing or removing signs of the disease or disorder. As anotherexample, administration of a TNFα inhibitor after clinical manifestationof psoriasis to combat the symptoms and/or complications and disordersassociated with psoriasis comprises “treatment” of the disease. Further,administration of the agent after onset and after clinical symptomsand/or complications have developed where administration affectsclinical parameters of the disease or disorder and perhaps ameliorationof the disease, comprises “treatment” of the psoriasis. In oneembodiment, treatment of psoriasis in a subject comprises inducing andmaintaining remission of psoriasis in a subject. In another embodiment,treatment of psoriasis in a subject comprises maintaining remission ofpsoriasis in a subject.

Those “in need of treatment” include mammals, such as humans, alreadyhaving psoriasis, including those in which the disease or disorder is tobe prevented.

Various aspects of the invention are described in further detail herein.

The invention provides improved uses and compositions for treatingpsoriasis disease with a TNFα inhibitor, e.g., a human TNFα antibody, oran antigen-binding portion thereof. Compositions and articles ofmanufacture, including kits, relating to the methods and uses fortreating psoriasis are also contemplated as part of the invention.

II. TNF Inhibitors

A TNFα inhibitor which is used in the methods and compositions of theinvention includes any agent which interferes with TNFα activity. In apreferred embodiment, the TNFα inhibitor can neutralize TNFα activity,particularly detrimental TNFα activity which is associated withpsoriasis, and related complications and symptoms.

In one embodiment, the TNFα inhibitor used in the invention is an TNFαantibody (also referred to herein as a TNFα antibody), or anantigen-binding fragment thereof, including chimeric, humanized, andhuman antibodies. Examples of TNFα antibodies which may be used in theinvention include, but not limited to, infliximab (Remicade®, Johnsonand Johnson; described in U.S. Pat. No. 5,656,272, incorporated byreference herein), CDP571 (a humanized monoclonal anti-TNF-alpha IgG4antibody), CDP 870 (a humanized monoclonal anti-TNF-alpha antibodyfragment), an anti-TNF dAb (Peptech), CNTO 148 (golimumab; Medarex andCentocor, see WO 02/12502), and adalimumab (HUMIRA® Abbott Laboratories,a human anti-TNF mAb, described in U.S. Pat. No. 6,090,382 as D2E7).Additional TNF antibodies which may be used in the invention aredescribed in U.S. Pat. Nos. 6,593,458; 6,498,237; 6,451,983; and6,448,380, each of which is incorporated by reference herein.

Other examples of TNFα inhibitors which may be used in the methods andcompositions of the invention include etanercept (Enbrel, described inWO 91/03553 and WO 09/406476), soluble TNF receptor Type I, a pegylatedsoluble TNF receptor Type I (PEGs TNF-R1), p55TNFR1gG (Lenercept), andrecombinant TNF binding protein (r-TBP-I) (Serono).

In one embodiment, the term “TNFα inhibitor” excludes infliximab. In oneembodiment, the term “TNFα inhibitor” excludes adalimumab. In anotherembodiment, the term “TNFα inhibitor” excludes adalimumab andinfliximab.

In one embodiment, the term “TNFα inhibitor” excludes etanercept, and,optionally, adalimumab, infliximab, and adalimumab and infliximab.

In one embodiment, the term “TNFα antibody” excludes infliximab. In oneembodiment, the term “TNFα antibody” excludes adalimumab. In anotherembodiment, the term “TNFα antibody” excludes adalimumab and infliximab.

In one embodiment, the invention features methods and compositions fortreating or determining the efficacy of a TNFα inhibitor for thetreatment of a skin disorder in which TNFα activity is detrimental,e.g., psoriasis, wherein the TNFα antibody is an isolated humanantibody, or antigen-binding portion thereof, that binds to human TNFαwith high affinity and a low off rate, and also has a high neutralizingcapacity. Preferably, the human antibodies used in the invention arerecombinant, neutralizing human anti-hTNFα antibodies. The mostpreferred recombinant, neutralizing antibody of the invention isreferred to herein as D2E7, also referred to as HUMIRA® or adalimumab(the amino acid sequence of the D2E7 VL region is shown in SEQ ID NO: 1;the amino acid sequence of the D2E7 VH region is shown in SEQ ID NO: 2).The properties of D2E7 (adalimumab/HUMIRA®) have been described inSalfeld et al., U.S. Pat. Nos. 6,090,382, 6,258,562, and 6,509,015,which are each incorporated by reference herein. The methods of theinvention may also be performed using chimeric and humanized murineanti-hTNFα antibodies which have undergone clinical testing fortreatment of rheumatoid arthritis (see e.g., Elliott, M. J., et al.(1994) Lancet 344:1125-1127; Elliot, M. J., et al. (1994) Lancet344:1105-1110; Rankin, E. C., et al. (1995) Br. J. Rheumatol.34:334-342).

In certain embodiments, the TNFα inhibitor used in the invention areD2E7 antibodies and antibody portions, D2E7-related antibodies andantibody portions, or other human antibodies and antibody portions withequivalent properties to D2E7, such as high affinity binding to hTNFαwith low dissociation kinetics and high neutralizing capacity. In oneembodiment, the invention provides treatment with an isolated humanantibody, or an antigen-binding portion thereof, that dissociates fromhuman TNFα with a K_(d) of 1×10⁻⁸ M or less and a K_(off) rate constantof 1×10⁻³s⁻¹ or less, both determined by surface plasmon resonance, andneutralizes human TNFα cytotoxicity in a standard in vitro L929 assaywith an IC₅₀ of 1×10⁻⁷ M or less. More preferably, the isolated humanantibody, or antigen-binding portion thereof, dissociates from human

TNFα with a K_(off) of 5×10⁻⁴s⁻¹ or less, or even more preferably, witha K_(off) of 1×10⁻⁴s⁻¹ or less. More preferably, the isolated humanantibody, or antigen-binding portion thereof, neutralizes human TNFαcytotoxicity in a standard in vitro L929 assay with an IC₅₀ of 1×10⁻⁸ Mor less, even more preferably with an IC₅₀ of 1×10⁻⁹ M or less and stillmore preferably with an IC₅₀ of 1×10⁻¹⁰ M or less. In a preferredembodiment, the antibody is an isolated human recombinant antibody, oran antigen-binding portion thereof.

It is well known in the art that antibody heavy and light chain CDR3domains play an important role in the binding specificity/affinity of anantibody for an antigen. Accordingly, in another aspect, the inventionpertains to treating psoriasis by administering human antibodies thathave slow dissociation kinetics for association with hTNFα and that havelight and heavy chain CDR3 domains that structurally are identical to toor related to those of D2E7. Position 9 of the D2E7 VL CDR3 can beoccupied by

Ala or Thr without substantially affecting the K_(off). Accordingly, aconsensus motif for the D2E7 VL CDR3 comprises the amino acid sequence:Q-R-Y-N-R-A-P-Y-(T/A) (SEQ ID NO: 3). Additionally, position 12 of theD2E7 VH CDR3 can be occupied by Tyr or Asn, without substantiallyaffecting the K_(off). Accordingly, a consensus motif for the D2E7 VHCDR3 comprises the amino acid sequence: V-S-Y-L-S-T-A-S-S-L-D-(Y/N) (SEQID NO: 4). Moreover, as demonstrated in Example 2 of U.S. Pat. No.6,090,382, the CDR3 domain of the D2E7 heavy and light chains isamenable to substitution with a single alanine residue (at position 1,4, 5, 7 or 8 within the VL CDR3 or at position 2, 3, 4, 5, 6, 8, 9, 10or 11 within the VH CDR3) without substantially affecting the K_(off).Still further, the skilled artisan will appreciate that, given theamenability of the D2E7 VL and VH CDR3 domains to substitutions byalanine, substitution of other amino acids within the CDR3 domains maybe possible while still retaining the low off rate constant of theantibody, in particular substitutions with conservative amino acids.Preferably, no more than one to five conservative amino acidsubstitutions are made within the D2E7 VL and/or VH CDR3 domains. Morepreferably, no more than one to three conservative amino acidsubstitutions are made within the D2E7 VL and/or VH CDR3 domains.Additionally, conservative amino acid substitutions should not be madeat amino acid positions critical for binding to hTNFα. Positions 2 and 5of the D2E7 VL CDR3 and positions 1 and 7 of the D2E7 VH CDR3 appear tobe critical for interaction with hTNFα and thus, conservative amino acidsubstitutions preferably are not made at these positions (although analanine substitution at position 5 of the D2E7 VL CDR3 is acceptable, asdescribed above) (see U.S. Pat. No. 6,090,382).

Accordingly, in another embodiment, the antibody or antigen-bindingportion thereof preferably contains the following characteristics:

a) dissociates from human TNFα with a K_(off) rate constant of 1×10⁻³s⁻¹or less, as determined by surface plasmon resonance;

b) has a light chain CDR3 domain comprising the amino acid sequence ofSEQ ID NO: 3, or modified from SEQ ID NO: 3 by a single alaninesubstitution at position 1, 4, 5, 7 or 8 or by one to five conservativeamino acid substitutions at positions 1, 3, 4, 6, 7, 8 and/or 9;

c) has a heavy chain CDR3 domain comprising the amino acid sequence ofSEQ

ID NO: 4, or modified from SEQ ID NO: 4 by a single alanine substitutionat position 2, 3, 4, 5, 6, 8, 9, 10 or 11 or by one to five conservativeamino acid substitutions at positions 2, 3, 4, 5, 6, 8, 9, 10, 11 and/or12.

More preferably, the antibody, or antigen-binding portion thereof,dissociates to from human TNFα with a K_(off) of 5×10⁻⁴s⁻¹ or less. Evenmore preferably, the antibody, or antigen-binding portion thereof,dissociates from human TNFα with a K_(off) of 1×10⁻⁴s⁻¹ or less.

In yet another embodiment, the antibody or antigen-binding portionthereof preferably contains a light chain variable region (LCVR) havinga CDR3 domain comprising the amino acid sequence of SEQ ID NO: 3, ormodified from SEQ ID NO: 3 by a single alanine substitution at position1, 4, 5, 7 or 8, and with a heavy chain variable region (HCVR) having aCDR3 domain comprising the amino acid sequence of SEQ ID NO: 4, ormodified from SEQ ID NO: 4 by a single alanine substitution at position2, 3, 4, 5, 6, 8, 9, 10 or 11. Preferably, the LCVR further has a CDR2domain comprising the amino acid sequence of SEQ ID NO: 5 (i.e., theD2E7 VL CDR2) and the HCVR further has a CDR2 domain comprising theamino acid sequence of SEQ ID NO: 6 (i.e., the D2E7 VH CDR2). Even morepreferably, the LCVR further has CDR1 domain comprising the amino acidsequence of SEQ ID NO: 7 (i.e., the D2E7 VL CDR1) and the HCVR has aCDR1 domain comprising the amino acid sequence of SEQ ID NO: 8 (i.e.,the D2E7 VH CDR1). The framework regions for VL preferably are from theV_(κ)I human germline family, more preferably from the A20 humangermline Vk gene and most preferably from the D2E7 VL frameworksequences shown in FIGS. 1A and 1B of U.S. Pat. No. 6,090,382. Theframework regions for VH preferably are from the V_(H)3 human germlinefamily, more preferably from the DP-31 human germline VH gene and mostpreferably from the D2E7 VH framework sequences shown in FIGS. 2A and 2Bof U.S. Pat. No. 6,090,382.

Accordingly, in another embodiment, the antibody or antigen-bindingportion thereof preferably contains a light chain variable region (LCVR)comprising the amino acid sequence of SEQ ID NO: 1 (i. e. , the D2E7 VL)and a heavy chain variable region (HCVR) comprising the amino acidsequence of SEQ ID NO: 2 (i. e. , the D2E7 VH). In certain embodiments,the antibody comprises a heavy chain constant region, such as an IgG1,IgG2, IgG3, IgG4, IgA, IgE, IgM or IgD constant region. Preferably, theheavy chain constant region is an IgG1 heavy chain constant region or anIgG4 heavy chain constant region. Furthermore, the antibody can comprisea light chain constant region, either a kappa light chain constantregion or a lambda light chain constant region. Preferably, the antibodycomprises a kappa light chain constant region. Alternatively, theantibody portion can be, for example, a Fab fragment or a single chainFv fragment.

In still other embodiments, the invention includes uses of an isolatedhuman antibody, or an antigen-binding portions thereof, containingD2E7-related VL and VH CDR3 domains. For example, antibodies, orantigen-binding portions thereof, with a light chain variable region(LCVR) having a CDR3 domain comprising an amino acid sequence selectedfrom the group consisting of SEQ ID NO: 3, SEQ ID NO: 11, SEQ ID NO: 12,SEQ ID NO: 13, SEQ ID NO: 14, SEQ ID NO: 15, SEQ ID NO: 16, SEQ ID NO:17, SEQ ID NO: 18, SEQ ID NO: 19, SEQ ID NO: 20, SEQ ID NO: 21, SEQ IDNO: 22, SEQ ID NO: 23, SEQ ID NO: 24, SEQ ID NO: 25 and SEQ ID NO: 26 orwith a heavy chain variable region (HCVR) having a CDR3 domaincomprising an amino acid sequence selected from the group consisting ofSEQ ID NO: 4, SEQ ID NO: 27, SEQ ID NO: 28, SEQ ID NO: 29, SEQ ID NO:30, SEQ ID NO: 31, SEQ ID NO: 32, SEQ ID NO: 33, SEQ ID NO: 34 and SEQID NO: 35.

The TNFα antibody used in the methods and compositions of the inventionmay be modified for improved treatment of psoriasis. In someembodiments, the TNFα antibody or antigen binding fragments thereof, ischemically modified to provide a desired effect. For example, pegylationof antibodies and antibody fragments of the invention may be carried outby any of the pegylation reactions known in the art, as described, forexample, in the following references: Focus on Growth Factors 3:4-10(1992); EP 0 154 316; and EP 0 401 384 (each of which is incorporated byreference herein in its entirety). Preferably, the pegylation is carriedout via an acylation reaction or an alkylation reaction with a reactivepolyethylene glycol molecule (or an analogous reactive water-solublepolymer). A preferred water-soluble polymer for pegylation of theantibodies and antibody fragments of the invention is polyethyleneglycol (PEG). As used herein, “polyethylene glycol” is meant toencompass any of the forms of PEG that have been used to derivatizeother proteins, such as mono (Cl-ClO) alkoxy- or aryloxy-polyethyleneglycol.

Methods for preparing pegylated antibodies and antibody fragments of theinvention will generally comprise the steps of (a) reacting the antibodyor antibody fragment with polyethylene glycol, such as a reactive esteror aldehyde derivative of PEG, under conditions whereby the antibody orantibody fragment becomes attached to one or more PEG groups, and (b)obtaining the reaction products. It will be apparent to one of ordinaryskill in the art to select the optimal reaction conditions or theacylation reactions based on known parameters and the desired result.

Pegylated antibodies and antibody fragments may generally be used totreat psoriasis by administration of the TNFα antibodies and antibodyfragments described herein. Generally the pegylated antibodies andantibody fragments have increased half-life, as compared to thenonpegylated antibodies and antibody fragments. The pegylated antibodiesand antibody fragments may be employed alone, together, or incombination with other pharmaceutical compositions.

In yet another embodiment of the invention, TNFα antibodies or fragmentsthereof can be altered wherein the constant region of the antibody ismodified to reduce at least one constant region-mediated biologicaleffector function relative to an to unmodified antibody. To modify anantibody of the invention such that it exhibits reduced binding to theFc receptor, the immunoglobulin constant region segment of the antibodycan be mutated at particular regions necessary for Fc receptor (FcR)interactions (see e.g., Canfield, S. M. and S. L. Morrison (1991) J.Exp. Med. 173:1483-1491; and Lund, J. et al. (1991) J. of Immunol.147:2657-2662). Reduction in FcR binding ability of the antibody mayalso reduce other effector functions which rely on FcR interactions,such as opsonization and phagocytosis and antigen-dependent cellularcytotoxicity.

An antibody or antibody portion used in the methods of the invention canbe derivatized or linked to another functional molecule (e.g., anotherpeptide or protein). Accordingly, the antibodies and antibody portionsof the invention are intended to include derivatized and otherwisemodified forms of the human anti-hTNFα antibodies described herein,including immunoadhesion molecules. For example, an antibody or antibodyportion of the invention can be functionally linked (by chemicalcoupling, genetic fusion, noncovalent association or otherwise) to oneor more other molecular entities, such as another antibody (e.g., abispecific antibody or a diabody), a detectable agent, a cytotoxicagent, a pharmaceutical agent, and/or a protein or peptide that canmediate associate of the antibody or antibody portion with anothermolecule (such as a streptavidin core region or a polyhistidine tag).

One type of derivatized antibody is produced by crosslinking two or moreantibodies (of the same type or of different types, e.g., to createbispecific antibodies). Suitable crosslinkers include those that areheterobifunctional, having two distinctly reactive groups separated byan appropriate spacer (e.g., m-maleimidobenzoyl-N-hydroxysuccinimideester) or homobifunctional (e.g., disuccinimidyl suberate). Such linkersare available from Pierce Chemical Company, Rockford, Ill.

Useful detectable agents with which an antibody or antibody portion ofthe invention may be derivatized include fluorescent compounds.Exemplary fluorescent detectable agents include fluorescein, fluoresceinisothiocyanate, rhodamine, 5-dimethylamine-1-napthalenesulfonylchloride, phycoerythrin and the like. An antibody may also bederivatized with detectable enzymes, such as alkaline phosphatase,horseradish peroxidase, glucose oxidase and the like. When an antibodyis derivatized with a detectable enzyme, it is detected by addingadditional reagents that the enzyme uses to produce a detectablereaction product. For example, when the detectable agent horseradishperoxidase is present, the addition of hydrogen peroxide anddiaminobenzidine leads to a colored reaction product, which isdetectable. An antibody may also be derivatized with biotin, anddetected through indirect measurement of avidin or streptavidin binding.

An antibody, or antibody portion, used in the methods and compositionsof the to invention, can be prepared by recombinant expression ofimmunoglobulin light and heavy chain genes in a host cell. To express anantibody recombinantly, a host cell is transfected with one or morerecombinant expression vectors carrying DNA fragments encoding theimmunoglobulin light and heavy chains of the antibody such that thelight and heavy chains are expressed in the host cell and, preferably,secreted into the medium in which the host cells are cultured, fromwhich medium the antibodies can be recovered. Standard recombinant DNAmethodologies are used to obtain antibody heavy and light chain genes,incorporate these genes into recombinant expression vectors andintroduce the vectors into host cells, such as those described inSambrook, Fritsch and Maniatis (eds), Molecular Cloning; A LaboratoryManual, Second Edition, Cold Spring Harbor, N.Y., (1989), Ausubel, F. M.et al. (eds.) Current Protocols in Molecular Biology, Greene PublishingAssociates, (1989) and in U.S. Pat. No. 4,816,397 by Boss et al.

To express antibodies, such as adalimumab (D2E7) or an adalimumab(D2E7)-related antibody, DNA fragments encoding the light and heavychain variable regions are first obtained. These DNAs can be obtained byamplification and modification of germline light and heavy chainvariable sequences using the polymerase chain reaction (PCR). GermlineDNA sequences for human heavy and light chain variable region genes areknown in the art (see e.g., the “Vbase” human germline sequencedatabase; see also Kabat, E. A., et al. (1991) Sequences of Proteins ofImmunological Interest, Fifth Edition, U.S. Department of Health andHuman Services, NIH Publication No. 91-3242; Tomlinson, I. M., et al.(1992) “The Repertoire of Human Germline V_(H) Sequences Reveals aboutFifty Groups of V_(H) Segments with Different Hypervariable Loops” J.Mol. Biol. 227:776-798; and Cox, J. P. L. et al. (1994) “A Directory ofHuman Germ-line V₇₈ Segments Reveals a Strong Bias in their Usage” Eur.J. Immunol. 24:827-836; the contents of each of which are expresslyincorporated herein by reference). To obtain a DNA fragment encoding theheavy chain variable region of D2E7, or a D2E7-related antibody, amember of the V_(H)3 family of human germline VH genes is amplified bystandard PCR. Most preferably, the DP-31 VH germline sequence isamplified. To obtain a DNA fragment encoding the light chain variableregion of D2E7, or a D2E7-related antibody, a member of the V₇₈I familyof human germline VL genes is amplified by standard PCR. Mostpreferably, the A20 VL germline sequence is amplified. PCR primerssuitable for use in amplifying the DP-31 germline VH and A20 germline VLsequences can be designed based on the nucleotide sequences disclosed inthe references cited supra, using standard methods.

Once the germline VH and VL fragments are obtained, these sequences canbe mutated to encode the D2E7 or D2E7-related amino acid sequencesdisclosed herein. The amino acid sequences encoded by the germline VHand VL DNA sequences are to first compared to the D2E7 or D2E7-relatedVH and VL amino acid sequences to identify amino acid residues in theD2E7 or D2E7-related sequence that differ from germline. Then, theappropriate nucleotides of the germline DNA sequences are mutated suchthat the mutated germline sequence encodes the D2E7 or D2E7-relatedamino acid sequence, using the genetic code to determine whichnucleotide changes should be made. Mutagenesis of the germline sequencesis carried out by standard methods, such as PCR-mediated mutagenesis (inwhich the mutated nucleotides are incorporated into the PCR primers suchthat the PCR product contains the mutations) or site-directedmutagenesis.

Moreover, it should be noted that if the “germline” sequences obtainedby PCR amplification encode amino acid differences in the frameworkregions from the true germline configuration (i.e., differences in theamplified sequence as compared to the true germline sequence, forexample as a result of somatic mutation), it may be desireable to changethese amino acid differences back to the true germline sequences (i.e.,“backmutation” of framework residues to the germline configuration).

Once DNA fragments encoding D2E7 or D2E7-related VH and VL segments areobtained (by amplification and mutagenesis of germline VH and VL genes,as described above), these DNA fragments can be further manipulated bystandard recombinant DNA techniques, for example to convert the variableregion genes to full-length antibody chain genes, to Fab fragment genesor to a scFv gene. In these manipulations, a VL- or VH-encoding DNAfragment is operatively linked to another DNA fragment encoding anotherprotein, such as an antibody constant region or a flexible linker. Theterm “operatively linked”, as used in this context, is intended to meanthat the two DNA fragments are joined such that the amino acid sequencesencoded by the two DNA fragments remain in-frame.

The isolated DNA encoding the VH region can be converted to afull-length heavy chain gene by operatively linking the VH-encoding DNAto another DNA molecule encoding heavy chain constant regions (CH1, CH2and CH3). The sequences of human heavy chain constant region genes areknown in the art (see e.g., Kabat, E. A., et al. (1991) Sequences ofProteins of Immunological Interest, Fifth Edition, U.S. Department ofHealth and Human Services, NIH Publication No. 91-3242) and DNAfragments encompassing these regions can be obtained by standard PCRamplification. The heavy chain constant region can be an IgG1, IgG2,IgG3, IgG4, IgA, IgE, IgM or IgD constant region, but most preferably isan IgG1 or IgG4 constant region. For a Fab fragment heavy chain gene,the VH-encoding DNA can be operatively linked to another DNA moleculeencoding only the heavy chain CH1 constant region.

The isolated DNA encoding the VL region can be converted to afull-length light chain gene (as well as a Fab light chain gene) byoperatively linking the VL-encoding to DNA to another DNA moleculeencoding the light chain constant region, CL. The sequences of humanlight chain constant region genes are known in the art (see e.g., Kabat,E. A., et al. (1991) Sequences of Proteins of Immunological Interest,Fifth Edition, U.S. Department of Health and Human Services, NIHPublication No. 91-3242) and DNA fragments encompassing these regionscan be obtained by standard PCR amplification. The light chain constantregion can be a kappa or lambda constant region, but most preferably isa kappa constant region.

To create a scFv gene, the VH- and VL-encoding DNA fragments areoperatively linked to another fragment encoding a flexible linker, e.g.,encoding the amino acid sequence (Gly₄-Ser)₃, such that the VH and VLsequences can be expressed as a contiguous single-chain protein, withthe VL and VH regions joined by the flexible linker (see e.g., Bird etal. (1988) Science 242:423-426; Huston et al. (1988) Proc. Natl. Acad.Sci. USA 85:5879-5883; McCafferty et al., Nature (1990) 348:552-554).

To express the antibodies, or antibody portions used in the invention,DNAs encoding partial or full-length light and heavy chains, obtained asdescribed above, are inserted into expression vectors such that thegenes are operatively linked to transcriptional and translationalcontrol sequences. In this context, the term “operatively linked” isintended to mean that an antibody gene is ligated into a vector suchthat transcriptional and translational control sequences within thevector serve their intended function of regulating the transcription andtranslation of the antibody gene. The expression vector and expressioncontrol sequences are chosen to be compatible with the expression hostcell used. The antibody light chain gene and the antibody heavy chaingene can be inserted into separate vector or, more typically, both genesare inserted into the same expression vector. The antibody genes areinserted into the expression vector by standard methods (e.g., ligationof complementary restriction sites on the antibody gene fragment andvector, or blunt end ligation if no restriction sites are present).Prior to insertion of the D2E7 or D2E7-related light or heavy chainsequences, the expression vector may already carry antibody constantregion sequences. For example, one approach to converting the D2E7 orD2E7-related VH and VL sequences to full-length antibody genes is toinsert them into expression vectors already encoding heavy chainconstant and light chain constant regions, respectively, such that theVH segment is operatively linked to the CH segment(s) within the vectorand the VL segment is operatively linked to the CL segment within thevector. Additionally or alternatively, the recombinant expression vectorcan encode a signal peptide that facilitates secretion of the antibodychain from a host cell. The antibody chain gene can be cloned into thevector such that the signal peptide is linked in-frame to the aminoterminus of the antibody chain gene. The signal peptide can be animmunoglobulin signal peptide or a heterologous signal peptide (i.e., asignal peptide from a non-immunoglobulin protein).

In addition to the antibody chain genes, the recombinant expressionvectors of the invention carry regulatory sequences that control theexpression of the antibody chain genes in a host cell. The term“regulatory sequence” is intended to include promoters, enhancers andother expression control elements (e.g., polyadenylation signals) thatcontrol the transcription or translation of the antibody chain genes.Such regulatory sequences are described, for example, in Goeddel; GeneExpression Technology: Methods in Enzymology 185, Academic Press, SanDiego, Calif. (1990). It will be appreciated by those skilled in the artthat the design of the expression vector, including the selection ofregulatory sequences may depend on such factors as the choice of thehost cell to be transformed, the level of expression of protein desired,etc. Preferred regulatory sequences for mammalian host cell expressioninclude viral elements that direct high levels of protein expression inmammalian cells, such as promoters and/or enhancers derived fromcytomegalovirus (CMV) (such as the CMV promoter/enhancer), Simian Virus40 (SV40) (such as the SV40 promoter/enhancer), adenovirus, (e.g., theadenovirus major late promoter (AdMLP)) and polyoma. For furtherdescription of viral regulatory elements, and sequences thereof, seee.g., U.S. Pat. No. 5,168,062 by Stinski, U.S. Pat. No. 4,510,245 byBell et al. and U.S. Pat. No. 4,968,615 by Schaffner et al.

In addition to the antibody chain genes and regulatory sequences, therecombinant expression vectors used in the invention may carryadditional sequences, such as sequences that regulate replication of thevector in host cells (e.g., origins of replication) and selectablemarker genes. The selectable marker gene facilitates selection of hostcells into which the vector has been introduced (see e.g., U.S. Pat.Nos. 4,399,216, 4,634,665 and 5,179,017, all by Axel et al.). Forexample, typically the selectable marker gene confers resistance todrugs, such as G418, hygromycin or methotrexate, on a host cell intowhich the vector has been introduced. Preferred selectable marker genesinclude the dihydrofolate reductase (DHFR) gene (for use in dhfr⁻hostcells with methotrexate selection/amplification) and the neo gene (forG418 selection).

For expression of the light and heavy chains, the expression vector(s)encoding the heavy and light chains is transfected into a host cell bystandard techniques. The various forms of the term “transfection” areintended to encompass a wide variety of techniques commonly used for theintroduction of exogenous DNA into a prokaryotic or eukaryotic hostcell, e.g., electroporation, calcium-phosphate precipitation,DEAE-dextran transfection and the like. Although it is theoreticallypossible to express the antibodies of the invention in eitherprokaryotic or eukaryotic host cells, expression of antibodies ineukaryotic cells, and most preferably mammalian host cells, is the mostpreferred because such eukaryotic cells, and in particular mammaliancells, are more likely than prokaryotic cells to assemble and secrete aproperly folded and immunologically active antibody. Prokaryoticexpression of antibody genes has been reported to be ineffective forproduction of high yields of active antibody (Boss, M. A. and Wood, C.R. (1985) Immunology Today 6:12-13).

Preferred mammalian host cells for expressing the recombinant antibodiesof the invention include Chinese Hamster Ovary (CHO cells) (includingdhfr-CHO cells, described in Urlaub and Chasin, (1980) Proc. Natl. Acad.Sci. USA 77:4216-4220, used with a DHFR selectable marker, e.g., asdescribed in R. J. Kaufman and P. A. Sharp (1982) Mol. Biol.159:601-621), NSO myeloma cells, COS cells and SP2 cells. Whenrecombinant expression vectors encoding antibody genes are introducedinto mammalian host cells, the antibodies are produced by culturing thehost cells for a period of time sufficient to allow for expression ofthe antibody in the host cells or, more preferably, secretion of theantibody into the culture medium in which the host cells are grown.Antibodies can be recovered from the culture medium using standardprotein purification methods.

Host cells can also be used to produce portions of intact antibodies,such as Fab fragments or scFv molecules. It is understood thatvariations on the above procedure are within the scope of the presentinvention. For example, it may be desirable to transfect a host cellwith DNA encoding either the light chain or the heavy chain (but notboth) of an antibody of this invention. Recombinant DNA technology mayalso be used to remove some or all of the DNA encoding either or both ofthe light and heavy chains that is not necessary for binding to hTNFα.The molecules expressed from such truncated DNA molecules are alsoencompassed by the antibodies of the invention. In addition,bifunctional antibodies may be produced in which one heavy and one lightchain are an antibody of the invention and the other heavy and lightchain are specific for an antigen other than hTNFα by crosslinking anantibody of the invention to a second antibody by standard chemicalcrosslinking methods.

In a preferred system for recombinant expression of an antibody, orantigen-binding portion thereof, of the invention, a recombinantexpression vector encoding both the antibody heavy chain and theantibody light chain is introduced into dhfr-CHO cells by calciumphosphate-mediated transfection. Within the recombinant expressionvector, the antibody heavy and light chain genes are each operativelylinked to CMV enhancer/AdMLP promoter regulatory elements to drive highlevels of transcription of the genes. The recombinant expression vectoralso carries a DHFR gene, which allows for selection of CHO cells thathave been transfected with the vector using methotrexateselection/amplification. The selected transformant host cells areculture to allow for expression of the antibody heavy and light chainsand intact antibody is recovered from the culture medium. Standardmolecular biology techniques are used to prepare the to recombinantexpression vector, transfect the host cells, select for transformants,culture the host cells and recover the antibody from the culture medium.

In view of the foregoing, nucleic acid, vector and host cellcompositions that can be used for recombinant expression of theantibodies and antibody portions used in the invention include nucleicacids, and vectors comprising said nucleic acids, comprising the humanTNFα antibody adalimumab (D2E7). The nucleotide sequence encoding theD2E7 light chain variable region is shown in SEQ ID NO: 36. The CDR1domain of the LCVR encompasses nucleotides 70-102, the CDR2 domainencompasses nucleotides 148-168 and the CDR3 domain encompassesnucleotides 265-291. The nucleotide sequence encoding the D2E7 heavychain variable region is shown in SEQ ID NO: 37. The CDR1 domain of theHCVR encompasses nucleotides 91-105, the CDR2 domain encompassesnucleotides 148-198 and the CDR3 domain encompasses nucleotides 295-330.It will be appreciated by the skilled artisan that nucleotide sequencesencoding D2E7-related antibodies, or portions thereof (e.g., a CDRdomain, such as a CDR3 domain), can be derived from the nucleotidesequences encoding the D2E7 LCVR and HCVR using the genetic code andstandard molecular biology techniques.

Recombinant human antibodies of the invention in addition to D2E7 or anantigen binding portion thereof, or D2E7-related antibodies disclosedherein can be isolated by screening of a recombinant combinatorialantibody library, preferably a scFv phage display library, preparedusing human VL and VH cDNAs prepared from mRNA derived from humanlymphocytes. Methodologies for preparing and screening such librariesare known in the art. In addition to commercially available kits forgenerating phage display libraries (e.g., the Pharmacia RecombinantPhage Antibody System, catalog no. 27-9400-01; and the StratageneSurfZAP™ phage display kit, catalog no. 240612), examples of methods andreagents particularly amenable for use in generating and screeningantibody display libraries can be found in, for example, Ladner et al.U.S. Pat. No. 5,223,409; Kang et al. PCT Publication No. WO 92/18619;Dower et al. PCT Publication No. WO 91/17271; Winter et al. PCTPublication No. WO 92/20791; Markland et al. PCT Publication No. WO92/15679; Breitling et al. PCT Publication No. WO 93/01288; McCaffertyet al. PCT Publication No. WO 92/01047; Garrard et al. PCT PublicationNo. WO 92/09690; Fuchs et al. (1991) Bio/Technology 9:1370-1372; Hay etal. (1992) Hum Antibod Hybridomas 3:81-65; Huse et al. (1989) Science246:1275-1281; McCafferty et al., Nature (1990) 348:552-554; Griffithset al. (1993) EMBO J 12:725-734; Hawkins et al. (1992) J Mol Biol226:889-896; Clackson et al. (1991) Nature 352:624-628; Gram et al.(1992) PNAS 89:3576-3580; Garrard et al. (1991) Bio/Technology9:1373-1377; Hoogenboom et al. (1991) Nuc Acid Res 19:4133-4137; andBarbas et al. (1991) PNAS 88:7978-7982.

In a preferred embodiment, to isolate human antibodies with highaffinity and a low off rate constant for hTNFα, a murine anti-hTNFαantibody having high affinity and a low off rate constant for hTNFα(e.g., MAK 195, the hybridoma for which has deposit number ECACC 87050801) is first used to select human heavy and light chain sequenceshaving similar binding activity toward hTNFα, using the epitopeimprinting methods described in Hoogenboom et al., PCT Publication No.WO 93/06213. The antibody libraries used in this method are preferablyscFv libraries prepared and screened as described in McCafferty et al.,PCT Publication No. WO 92/01047, McCafferty et al., Nature (1990)348:552-554; and Griffiths et al., (1993) EMBO J 12:725-734. The scFvantibody libraries preferably are screened using recombinant human TNFαas the antigen. Once initial human VL and VH segments are selected, “mixand match” experiments, in which different pairs of the initiallyselected VL and VH segments are screened for hTNFα binding, areperformed to select preferred VL/VH pair combinations. Additionally, tofurther improve the affinity and/or lower the off rate constant forhTNFα binding, the VL and VH segments of the preferred VL/VH pair(s) canbe randomly mutated, preferably within the CDR3 region of VH and/or VL,in a process analogous to the in vivo somatic mutation processresponsible for affinity maturation of antibodies during a naturalimmune response. This in vitro affinity maturation can be accomplishedby amplifying VH and VL regions using PCR primers complimentary to theVH CDR3 or VL CDR3, respectively, which primers have been “spiked” witha random mixture of the four nucleotide bases at certain positions suchthat the resultant PCR products encode VH and VL segments into whichrandom mutations have been introduced into the VH and/or VL CDR3regions. These randomly mutated VH and VL segments can be rescreened forbinding to hTNFα and sequences that exhibit high affinity and a low offrate for hTNFα binding can be selected.

Following screening and isolation of an anti-hTNFα antibody of theinvention from a recombinant immunoglobulin display library, nucleicacid encoding the selected antibody can be recovered from the displaypackage (e.g., from the phage genome) and subcloned into otherexpression vectors by standard recombinant DNA techniques. If desired,the nucleic acid can be further manipulated to create other antibodyforms of the invention (e.g., linked to nucleic acid encoding additionalimmunoglobulin domains, such as additional constant regions). To expressa recombinant human antibody isolated by screening of a combinatoriallibrary, the DNA encoding the antibody is cloned into a recombinantexpression vector and introduced into a mammalian host cells, asdescribed in further detail in above.

Methods of isolating human neutralizing antibodies with high affinityand a low off rate constant for hTNFα are described in U.S. Pat. Nos.6,090,382, 6,258,562, and 6,509,015, each of which is incorporated byreference herein.

Antibodies, antibody-portions, and other TNFα inhibitors for use in themethods of the invention, can be incorporated into pharmaceuticalcompositions suitable for administration to a subject. Typically, thepharmaceutical composition comprises an antibody, antibody portion, orother TNFα inhibitor, and a pharmaceutically acceptable carrier. As usedherein, “pharmaceutically acceptable carrier” includes any and allsolvents, dispersion media, coatings, antibacterial and antifungalagents, isotonic and absorption delaying agents, and the like that arephysiologically compatible. Examples of pharmaceutically acceptablecarriers include one or more of water, saline, phosphate bufferedsaline, dextrose, glycerol, ethanol and the like, as well ascombinations thereof. In many cases, it is preferable to includeisotonic agents, for example, sugars, polyalcohols such as mannitol,sorbitol, or sodium chloride in the composition. Pharmaceuticallyacceptable carriers may further comprise minor amounts of auxiliarysubstances such as wetting or emulsifying agents, preservatives orbuffers, which enhance the shelf life or effectiveness of the antibody,antibody portion, or other TNFα inhibitor.

The compositions for use in the methods and compositions of theinvention may be in a variety of forms. These include, for example,liquid, semi-solid and solid dosage forms, such as liquid solutions(e.g., injectable and infusible solutions), dispersions or suspensions,tablets, pills, powders, liposomes and suppositories. The preferred formdepends on the intended mode of administration and therapeuticapplication. Typical preferred compositions are in the form ofinjectable or infusible solutions, such as compositions similar to thoseused for passive immunization of humans with other antibodies or otherTNFα inhibitors. The preferred mode of administration is parenteral(e.g., intravenous, subcutaneous, intraperitoneal, intramuscular). In apreferred embodiment, the antibody or other TNFα inhibitor isadministered by intravenous infusion or injection. In another preferredembodiment, the antibody or other TNFα inhibitor is administered byintramuscular or subcutaneous injection.

Therapeutic compositions typically must be sterile and stable under theconditions of manufacture and storage. The composition can be formulatedas a solution, microemulsion, dispersion, liposome, or other orderedstructure suitable to high drug concentration. Sterile injectablesolutions can be prepared by incorporating the active compound (i.e.,antibody, antibody portion, or other TNFα inhibitor) in the requiredamount in an appropriate solvent with one or a combination ofingredients enumerated above, as required, followed by filteredsterilization. Generally, dispersions are prepared by incorporating theactive compound into a sterile vehicle that contains a basic dispersionmedium and the required other ingredients from those enumerated above.In the case of sterile powders for the preparation of sterile injectablesolutions, the preferred methods of preparation are vacuum drying andfreeze-drying that yields a powder of the active to ingredient plus anyadditional desired ingredient from a previously sterile-filteredsolution thereof. The proper fluidity of a solution can be maintained,for example, by the use of a coating such as lecithin, by themaintenance of the required particle size in the case of dispersion andby the use of surfactants. Prolonged absorption of injectablecompositions can be brought about by including in the composition anagent that delays absorption, for example, monostearate salts andgelatin.

In one embodiment, the invention includes pharmaceutical compositionscomprising an effective TNFα inhibitor and a pharmaceutically acceptablecarrier, wherein the effective TNFα inhibitor may be used to treatpsoriasis.

In one embodiment, the antibody or antibody portion for use in themethods of the invention is incorporated into a pharmaceuticalformulation as described in PCT/IB03/04502 and U.S. Appin. No.20040033228, incorporated by reference herein. This formulation includesa concentration 50 mg/ml of the antibody D2E7 (adalimumab), wherein onepre-filled syringe contains 40 mg of antibody for subcutaneousinjection.

The antibodies, antibody-portions, and other TNFα inhibitors of thepresent invention can be administered by a variety of methods known inthe art, although for many therapeutic applications, the preferredroute/mode of administration is parenteral, e.g., subcutaneousinjection. In another embodiment, administration is via intravenousinjection or infusion.

As will be appreciated by the skilled artisan, the route and/or mode ofadministration will vary depending upon the desired results. In certainembodiments, the active compound may be prepared with a carrier thatwill protect the compound against rapid release, such as a controlledrelease formulation, including implants, transdermal patches, andmicroencapsulated delivery systems. Biodegradable, biocompatiblepolymers can be used, such as ethylene vinyl acetate, polyanhydrides,polyglycolic acid, collagen, polyorthoesters, and polylactic acid. Manymethods for the preparation of such formulations are patented orgenerally known to those skilled in the art. See, e.g., Sustained andControlled Release Drug Delivery Systems, Robinson, ed., Dekker, Inc.,N.Y., 1978.

In one embodiment, the TNFα antibodies and inhibitors used in theinvention are delivered to a subject subcutaneously. In one embodiment,the subject administers the TNFα inhibitor, including, but not limitedto, TNFα antibody, or antigen-binding portion thereof, tohimself/herself.

The TNFα antibodies and inhibitors used in the invention may also beadministered in the form of protein crystal formulations which include acombination of protein crystals encapsulated within a polymeric carrierto form coated particles. The coated particles of the protein crystalformulation may have a spherical morphology and be microspheres of up to500 micro meters in diameter or they may have some other to morphologyand be microparticulates. The enhanced concentration of protein crystalsallows the antibody of the invention to be delivered subcutaneously. Inone embodiment, the TNFα antibodies of the invention are delivered via aprotein delivery system, wherein one or more of a protein crystalformulation or composition, is administered to a subject with aTNFα-related disorder. Compositions and methods of preparing stabilizedformulations of whole antibody crystals or antibody fragment crystalsare also described in WO 02/072636, which is incorporated by referenceherein. In one embodiment, a formulation comprising the crystallizedantibody fragments described in PCT/IB03/04502 and U.S. Appln. No.20040033228, incorporated by reference herein, are used to treatrheumatoid arthritis using the treatment methods of the invention.

In certain embodiments, an antibody, antibody portion, or other TNFαinhibitor of the invention may be orally administered, for example, withan inert diluent or an assimilable edible carrier. The compound (andother ingredients, if desired) may also be enclosed in a hard or softshell gelatin capsule, compressed into tablets, or incorporated directlyinto the subject's diet. For oral therapeutic administration, thecompounds may be incorporated with excipients and used in the form ofingestible tablets, buccal tablets, troches, capsules, elixirs,suspensions, syrups, wafers, and the like. To administer a compound ofthe invention by other than parenteral administration, it may benecessary to coat the compound with, or co-administer the compound with,a material to prevent its inactivation.

Supplementary active compounds can also be incorporated into thecompositions. In certain embodiments, an antibody or antibody portionfor use in the methods of the invention is coformulated with and/orcoadministered with one or more additional therapeutic agents, includinga TNFα inhibitor or antagonist. For example, an anti-hTNFα antibody orantibody portion of the invention may be coformulated and/orcoadministered with one or more additional antibodies that bind othertargets associated with TNFα related disorders (e.g., antibodies thatbind other cytokines or that bind cell surface molecules), one or morecytokines, soluble TNFα receptor (see e.g., PCT Publication No. WO94/06476) and/or one or more chemical agents that inhibit hTNFαproduction or activity (such as cyclohexane-ylidene derivatives asdescribed in PCT Publication No. WO 93/19751) or any combinationthereof. Furthermore, one or more antibodies of the invention may beused in combination with two or more of the foregoing therapeuticagents. Such combination therapies may advantageously utilize lowerdosages of the administered therapeutic agents, thus avoiding possibleside effects, complications or low level of response by the patientassociated with the various monotherapies.

The pharmaceutical compositions of the invention may include a“therapeutically effective amount” or a “prophylactically effectiveamount” of an antibody or antibody portion of the invention. A“therapeutically effective amount” refers to an amount to effective, atdosages and for periods of time necessary, to achieve the desiredtherapeutic result. A therapeutically effective amount of the antibody,antibody portion, or other TNFα inhibitor may vary according to factorssuch as the disease state, age, sex, and weight of the individual, andthe ability of the antibody, antibody portion, other TNFα inhibitor toelicit a desired response in the individual. A therapeutically effectiveamount is also one in which any toxic or detrimental effects of theantibody, antibody portion, or other TNFα inhibitor are outweighed bythe therapeutically beneficial effects. A “prophylactically effectiveamount” refers to an amount effective, at dosages and for periods oftime necessary, to achieve the desired prophylactic result. Typically,since a prophylactic dose is used in subjects prior to or at an earlierstage of disease, the prophylactically effective amount will be lessthan the therapeutically effective amount.

Additional description regarding methods and uses of the inventioncomprising administration of a TNFα inhibitor are described in Part IIIof this specification.

The invention also pertains to packaged pharmaceutical compositions orkits for administering the anti-TNF antibodies of the invention for thetreatment of Psoriasis. In one embodiment of the invention, the kitcomprises a TNFα inhibitor, such as an antibody and instructions foradministration of the TNFα inhibitor for treatment of Psoriasis. Theinstructions may describe how, e.g., subcutaneously, and when, e.g., atweek 0, week 2, week 4, etc., the different doses of TNFα inhibitorshall be administered to a subject for treatment.

Another aspect of the invention pertains to kits containing apharmaceutical composition comprising a TNFα inhibitor, such as anantibody, and a pharmaceutically acceptable carrier and one or morepharmaceutical compositions each comprising an additional therapeuticagent useful for treating psoriasis, and a pharmaceutically acceptablecarrier. Alternatively, the kit comprises a single pharmaceuticalcomposition comprising an anti-TNFα antibody, one or more drugs usefulfor treating psoriasis, and a pharmaceutically acceptable carrier. Theinstructions may describe how, e.g., subcutaneously, and when, e.g., atweek 0, week 2, week 4, etc., the different doses of TNFα inhibitorand/or the additional therapeutic agent shall be administered to asubject for treatment.

The kit may contain instructions for dosing of the pharmaceuticalcompositions for the treatment of psoriasis. Additional descriptionregarding articles of manufacture of the invention are described insubsection III.

The package or kit alternatively can contain the TNFα inhibitor and itcan be promoted for use, either within the package or throughaccompanying information, for the uses or treatment of the disordersdescribed herein. The packaged pharmaceuticals or kits further caninclude a second agent (as described herein) packaged with or copromotedwith instructions for using the second agent with a first agent (asdescribed herein).

III. Methods and Compositions for Treating Skin Disorders AssociatedWith Detrimental TNFα Activity

Tumor necrosis factor has been implicated in the pathophysiology ofcertain skin disorders. In one embodiment, the methods of the inventioncan be used to treat a subject having a skin disorder in which TNFαactivity is detrimental. The term “skin disorder” or “skin disease” asused interchangeably herein, refers to abnormalities, other than injurywounds, of the skin which have induced a state of inflammation. In oneembodiment, the skin disorder of the invention is an inflammatory skindisorder, wherein the skin is characterized by capillary dilatation,leukocytic infiltration, redness, heat, and/or pain. Examples of skindisorders include, but are not limited to, psoriasis, pemphigusvulgaris, scleroderma, atopic dermatitis, sarcoidosis, erythema nodosum,hidradenitis suppurative, lichen planus, Sweet's syndrome, and vitiligo.As used herein, the term “skin disorder in which TNFα activity isdetrimental” is intended to include skin disorders and other disordersin which the presence of TNFα in a subject suffering from the disorderhas been shown to be or is suspected of being either responsible for thepathophysiology of the disorder or a factor that contributes to aworsening of the disorder, e.g., psoriasis. Accordingly, skin disordersin which TNFα activity is detrimental are disorders in which inhibitionof TNFα activity is expected to alleviate the symptoms and/orprogression of the disorder. The use of the antibodies, antibodyportions, and other TNFα inhibitors of the invention in the treatment ofspecific skin disorders, e.g., psoriasis, is discussed further below.

Psoriasis

Tumor necrosis factor has been implicated in the pathophysiology ofpsoriasis (Takematsu et al. (1989) Arch Dermatol Res. 281:398; Victorand Gottlieb (2002) J Drugs Dermatol. 1(3):264). Psoriasis is describedas a skin inflammation (irritation and redness) characterized byfrequent episodes of redness, itching, and thick, dry, silvery scales onthe skin. In particular, lesions are formed which involve primary andsecondary alterations in epidermal proliferation, inflammatory responsesof the skin, and an expression of regulatory molecules such aslymphokines and inflammatory factors. Psoriatic skin is morphologicallycharacterized by an increased turnover of epidermal cells, thickenedepidermis, abnormal keratinization, inflammatory cell infiltrates intothe epidermis and polymorphonuclear leukocyte and lymphocyteinfiltration into the epidermis layer resulting in an increase in thebasal cell cycle. Psoriasis often involves the nails, which frequentlyexhibit pitting, separation of the nail, thickening, and todiscoloration. Psoriasis is often associated with other inflammatorydisorders, for example arthritis, including rheumatoid arthritis,inflammatory bowel disease (IBD), and Crohn's disease.

Evidence of psoriasis is most commonly seen on the trunk, elbows, knees,scalp, skin folds, or fingernails, but it may affect any or all parts ofthe skin. Normally, it takes about a month for new skin cells to move upfrom the lower layers to the surface. In psoriasis, this process takesonly a few days, resulting in a build-up of dead skin cells andformation of thick scales. Symptoms of psoriasis include: skin patches,that are dry or red, covered with silvery scales, raised patches ofskin, accompanied by red borders, that may crack and become painful, andthat are usually lovated on the elbows, knees, trunk, scalp, and hands;skin lesions, including pustules, cracking of the skin, and skinredness; joint pain or aching which may be associated with of arthritis,e.g., psoriatic arthritis.

Treatment for psoriasis often includes a topical corticosteroids,vitamin D analogs, and topical or oral retinoids, or combinationsthereof. In one embodiment, the TNFα inhibitor of the invention isadministered in combination with or the presence of one of these commontreatments. Additional therapeutic agents which can also be combinedwith the TNFα inhibitor of the invention for treatment of psoriasis aredescribed in more detail below.

The diagnosis of psoriasis is usually based on the appearance of theskin. Additionally a skin biopsy, or scraping and culture of skinpatches may be needed to rule out other skin disorders. An x-ray may beused to check for psoriatic arthritis if joint pain is present andpersistent.

Certain subtypes of psoriasis may be treated in accordance with theinvention. In one embodiment, moderate to severe psoriasis is treated byadministering a TNFα inhibitor, e.g, antibody, or antigen-bindingportion thereof, to a subject. The invention also provides a method fortreating certain subpopulations of psoriasis patients who may beespecially difficult to treat. For example, the invention provides amethod for treating patients who have a subtherapeutic response to atherapy, such as etanercept therapy.

In one embodiment of the invention, a TNFα inhibitor is used to treatpsoriasis, including chronic plaque psoriasis, guttate psoriasis,inverse psoriasis, pustular psoriasis, pemphigus vulgaris, erythrodermicpsoriasis, psoriasis associated with inflammatory bowel disease (IBD),and psoriasis associated with rheumatoid arthritis (RA). In oneembodiment, the methods of the invention are use to treat moderate tosevere psoriasis. Specific types of psoriasis included in the treatmentmethods of the invention are described in detail below:

a. Chronic plaque psoriasis

Tumor necrosis factor has been implicated in the pathophysiology ofchronic plaque psoriasis (Asadullah et al. (1999) Br J Dermatol.141:94).Chronic plaque psoriasis (also referred to as psoriasis vulgaris) is themost common form of psoriasis. Chronic plaque psoriasis is characterizedby raised reddened patches of skin, ranging from coin-sized to muchlarger. In chronic plaque psoriasis, the plaques may be single ormultiple, they may vary in size from a few millimeters to severalcentimeters. The plaques are usually red with a scaly surface, andreflect light when gently scratched, creating a “silvery” effect.Lesions (which are often symmetrical) from chronic plaque psoriasisoccur all over body, but with predilection for extensor surfaces,including the knees, elbows, lumbosacral regions, scalp, and nails.Occasionally chronic plaque psoriasis can occur on the penis, vulva andflexures, but scaling is usually absent. Diagnosis of patients withchronic plaque psoriasis is usually based on the clinical featuresdescribed above. In particular, the distribution, color and typicalsilvery scaling of the lesion in chronic plaque psoriasis arecharacteristic of chronic plaque psoriasis.

b. Guttate psoriasis

Guttate psoriasis refers to a form of psoriasis with characteristicwater drop shaped scaly plaques. Flares of guttate psoriasis generallyfollow an infection, most notably a streptococcal throat infection.Diagnosis of guttate psoriasis is usually based on the appearance of theskin, and the fact that there is often a history of recent sore throat.

c. Inverse psoriasis

Inverse psoriasis is a form of psoriasis in which the patient hassmooth, usually moist areas of skin that are red and inflammed, which isunlike the scaling associated with plaque psoriasis. Inverse psoriasisis also referred to as intertiginous psoriasis or flexural psoriasis.Inverse psoriasis occurs mostly in the armpits, groin, under the breastsand in other skin folds around the genitals and buttocks, and, as aresult of the locations of presentation, rubbing and sweating canirriate the affected areas.

d. Pustular psoriasis

Pustular psoriasis is a form of psoriasis that causes pus-filledblisters that vary in size and location, but often occur on the handsand feet. The blisters may be localized, or spread over large areas ofthe body. Pustular psoriasis can be both tender and painful, can causefevers.

e. Other psoriasis disorders

Other examples of psoriatic disorders which can be treated with the TNFαantibody of the invention include erythrodermic psoriasis, vulgaris,psoriasis associated with IBD, and psoriasis associated with arthritis,including rheumatoid arthritis.

Clinical Severity of Psoriasis

Severity of psoriasis may be determined according to standard clinicaldefinitions. For example, the Psoriasis Area and Severity Index (PASI)is used by dermatologists to assess psoriasis disease intensity. Thisindex is based on the quantitative assessment of three typical signs ofpsoriatic lesions: erythema, infiltration, and desquamation, combinedwith the skin surface area involvement. Since its development in 1978,this instrument has been used throughout the world by clinicalinvestigators (Fredriksson T, Petersson U: Severe psoriasis—oral therapywith a new retinoid. Dermatologica 1978; 157: 238-41). PASI is indicatedas PASI 50 (a 50 percent improvement in PASI from baseline), PASI 75 (a75 percent improvement in PASI from baseline), PASI 90 (a 90 percentimprovement in PASI from baseline), and PASI 100 (a 100 percentimprovement in PASI from baseline). The efficacy of a TNFα inhibitor fortreatment of psoriatic arthritis in a patient population who haspsoriasis, may be evaluated by determining the percentage of the patientpopulation in whom a PASI 50, PASI 75, PASI 90, or PASI 100 response hasbeen achieved following administration of the TNFα inhibitor.

The Physicians Global Assessment (PGA) is used to assess psoriasisactivity and follow clinical response to treatment. It is a six-pointscore that summarizes the overall quality (erythema, scaling andthickness) and extent of plaques relative to the baseline assessment. Apatient's response is rated as worse, poor (0-24%), fair (25-49%), good(50-74%), excellent (75-99%), or cleared (100%) (van der Kerkhof P. Thepsoriasis area and severity index and alternative approaches for theassessment of severity: persisting areas of confusion. Br J Dermatol1997; 137:661-662).

Another measure of improvement in the disease state of a subject havingpsoriasis includes clinical responses, such as the Dermatology LifeQuality Index (DLQI). Characteristics of the DLQI include:

ten items on an overall scoring range of 0-30; higher scores representgreater quality of life impairment and lower scores represent lowerquality of life impairment;

well-established properties of reliability and validity for the DLQItotal score in a dermatology setting (see Badia et al. (1999) Br JDermatol 141:698; Finlay et al. (1994) Clin Exp Dermatol 19:210; andShikier et al. (2003) Health and Quality of Life Outcomes 1:53);

six subcategories: symptoms and feelings; daily activities; leisure;work/school; personal relationships; and treatment;

all data are observed values. Patients who discontinued before the timepoint were not included in this analysis.

Ranges of DLQI scores can be evaluated for their correspondence tocategories of disease impact.

Other measures of improvements in the disease state of a subject havingpsoriasis include clinical responses, such as the Minnimum ClinicallyImportant Difference (MCID), described in more detail below in theExamples.

Methods of Treatment

In one aspect, the invention provides a method for treating patientshaving a skin disorder in which TNFα activity is detrimental, e.g.,psoriasis, who may be especially difficult to treat. For example, theinvention provides a method for treating patients who have asubtherapeutic response to a therapy (such as a biologic therapy), whohave failed to respond to a therapy, or have lost responsiveness to atherapy. In certain embodiments, the invention provides a method fortreating psoriasis patients who have a subtherapeutic response, who havefailed to respond to or have lost responsiveness to a biologic therapy,including, but not limited to, a TNF fusion proteins (e.g., etanercept),a soluble TNF receptor Type I, a pegylated soluble TNF receptor Type I(e.g., PEGs TNF-R1), p55TNFR1gG, a recombinant TNF binding protein(r-TBP-I) (Serono) and a TNFα antibody.

In one embodiment, the patients who have a subtherapeutic response to atherapy, who have failed to respond to a therapy, or have lostresponsiveness to a therapy are selected using the PASI score. In oneembodiment, the patient has failed to achieve a PASI 50. In oneembodiment, the patient has a PASI ≧10. In one embodiment, the therapyis a biologic therapy, e.g., a TNFα inhibitor biologic therapy.

In one embodiment, the patients who have a subtherapeutic response to atherapy, who have failed to respond to a therapy, or have lostresponsiveness to a therapy are selected measurement of DLQI. In oneembodiment, the patient has a DLQI >10. In another embodiment, thepatient has a PASI ≧10 and a DLQI >10. In one embodiment, the therapy isa biologic therapy, e.g., a TNFα inhibitor biologic therapy.

In one embodiment, the biologic therapy is entanercept. In oneembodiment, the invention provides a method for treating psoriasispatients who have a subtherapeutic response, who have failed to respondor have lost responsiveness to etanercept after prior failure of one ormore conventional psoriasis therapies. Conventional psoriasis totherapies include, but are not limited to, methotrexate, cyclosporine,psoralen, and PUVA (long-wave UV radiation) treatment.

In one embodiment, treatment of psoriasis is achieved by administering aTNFα inhibitor, e.g., a human TNFα antibody, or an antigen-bindingportion thereof, to a subject having psoriasis, wherein the TNFαinhibitor, e.g., human TNFα antibody, or an antigen-binding portionthereof, is administered on a biweekly dosing regimen.

Biweekly dosing regimens can be used to treat disorders in which TNFαactivity is detrimental, and are further described in US Appin. No.10/163657 (U.S. Pat. No. 20030235585), incorporated by reference herein.In one embodiment, biweekly dosing includes a dosing regimen whereindoses of a TNFα inhibitor are administered to a subject every other weekbeginning at week 1. In one embodiment, biweekly dosing includes adosing regimen where doses of a TNFα inhibitor are administered to asubject every other week consecutively for a given time period, e.g., 4weeks, 8 weeks, 16, weeks, 24 weeks, 26 weeks, 32 weeks, 36 weeks, 42weeks, 48 weeks, 52 weeks, 56 weeks, etc. Biweekly dosing is preferablyadministered parenterally, including subcutaneously. In one embodiment,the human TNFα antibody, or an antigen-binding portion thereof, isadministered biweekly at a fixed dose of about 40 mg. In one embodiment,the human TNFα antibody, or an antigen-binding portion thereof, isadalimumab. Additional examples of dosing regimens within the scope ofthe invention are provided herein in the Examples.

In one embodiment, treatment of psoriasis is achieved using multiplevariable dosing methods of treatment. Examples of such multiple variabledosing regimens are described in PCT appin. no. PCT/US05/12007,incorporated by reference herein. For example, a loading dose of about80 mg of a TNFα inhibitor may first be administered to a subject havingpsoriasis, followed by a maintenance or treatment dose of about 40 mg.

In one embodiment, the invention provides a method of treating psoriasisin a subject comprising administering an initial loading dose of a TNFαinhibitor to the subject at week 0. In one embodiment, the initial doseis given in its entirety on one day or is divided over 2 days. In oneembodiment, the initial dose is administered subcutaneously. Followingadministration of the initial loading dose, a second dose, i.e.,maintenance or treatment dose, of the TNFα inhibitor may be administeredto the subject, wherein the second dose is about half the dose amount ofthe initial loading dose. In one embodiment, the second dose isadministered to the subject about one week after the first dose. In oneembodiment, the second dose is administered subcutaneously. Subsequentdoses may be administered following the second dose in order to achievetreatment of the subject.

In another embodiment, the initial dose of the human TNFα antibody, orantigen-binding portion thereof, comprises 80 mg and may be given atweek 0, followed by at least one maintenance dose of the human TNFαantibody, or antigen-binding portion thereof, comprising 40 mg,administered on a biweekly dosing regimen.

In one embodiment of the invention, a human TNFα antibody, orantigen-binding portion thereof, is administered to a subject for thetreatment of psoriasis, including but not limited to moderate to severepsoriasis, where the subject has failed prior treatment with etanercept.The human TNFα antibody, or antigen-binding portion thereof, isadministered to the subject at an initial dose of 80 mg followed by 40mg every other week starting one week after the initial dose. The humanTNFα antibody, or antigen-binding portion thereof, is administeredsubcutaneously.

In another embodiment, the initial dose of human TNFα antibody, orantigen-binding portion thereof, comprises 80 mg and may be given atweek 0, and a second dose of 80 mg at week one, followed by at least onemaintenance dose comprising 40 mg of the human TNFα antibody, orantigen-binding portion thereof, administered on a biweekly dosingregimen.

In another embodiment, the initial dose of human TNFα antibody, orantigen-binding portion thereof, comprises 80 mg and may be given atweek 0, and a second dose of 80 mg at week one, followed by at least onemaintenance dose comprising 40 mg of the human TNFα antibody, orantigen-binding portion thereof, administered on a weekly dosing regimenfor a given period of time, e.g., 12 weeks, followed by biweeklyadministration of a maintenance dose comprising 40 mg of the human TNFαantibody, or antigen-binding portion thereof.

Dosage regimens described herein may be adjusted to provide the optimumdesired response, e.g., treating psoriasis, in consideration of theteachings herein. It is to be noted that dosage values may vary with thetype and severity of psoriasis. It is to be further understood that forany particular subject, specific dosage regimens may be adjusted overtime according to the teachings of the specification and the individualneed and the professional judgment of the person administering orsupervising the administration of the compositions, and that dosageamounts and ranges set forth herein are exemplary only and are notintended to limit the scope or practice of the claimed invention.

Methods of treatment described herein may include administration of aTNFα inhibitor, such as a human TNFα antibody, to a subject to achieve atherapeutic goal, using appropriate indices known in the art, e.g.,treatment of psoriasis, increase in

PASI response, maintenance of a level of PASI response, improvement inPASI score, and/or achievement of a PGA score of “clear” or “almostclear.” Also included in the scope of the invention are uses of a TNFαinhibitor in the manufacture of a medicament to achieve a therapeuticgoal, e.g., treatment, of psoriasis, increase in PASI response, tomaintenance of a level of PASI response, and/or improvement in PASIscore, and/or achievement of a PGA score of “clear” or “almost clear.”

The invention also provides methods for improving psoriasis in a subjectbased on indices used to measure the disease state. In one embodiment,the invention provides a method for improving the DLQI score of asubject. In one embodiment, the improvement in the DLQI score isdetermined by achieving a score correlating with a “no” or “smallimpact” of the disease state on the subject. In one embodiment, theimprovement in the DLQI score is determined by achieving an improvementin the DLQI score of the subject. Examples of such improvements areprovided in the examples described herein.

The invention also includes a method of decreasing a PGA score of asubject comprising administering a human TNFα antibody, orantigen-binding portion thereof, to the subject, such that partialremission of psoriasis is induced. In one embodiment, the inventionprovides an improvement of at least about 2 points in the PGA score of asubject having psoriasis. The invention also includes a method ofimproving the PASI score of a subject.

Subpopulations

The invention provides uses and methods for treating certainsubpopulations of patients having a skin disorder in which TNFα activityis detrimental, e.g., psoriasis, with a TNFα inhibitor.

In one embodiment, the invention provides a method of treating moderateto severe psoriasis in a subject comprising administering to the subjecta human TNFα antibody, such that moderate to severe psoriasis istreated. Subjects having moderate to severe psoriasis may beadministered a TNFα inhibitor such that moderate to severe psoriasis istreated and advancement of the disease is prevented. The invention alsoprovides use of a TNFα inhibitor in the manufacture of a medicament forthe treatment of moderate to severe psoriasis in a subject who hasmoderate to severe psoriasis. In a preferred embodiment, a patienthaving moderate to severe psoriasis is defined as a patient having aPASI score greater than 10, indicating a disease state.

The invention also provides a method for treating a subpopulation ofpatients having a skin disorder in which TNFα activity is detrimental,such as psoriasis, who are intolerant to or have lost response to aprevious biologic therapy, such as a first TNFα inhibitor therapy, e.g.,infliximab or etanercept. While clinical trials have demonstrated theefficacy of infliximab, a chimeric monoclonal antibody to TNFα, fortreatment of patients with moderate to severe psoriasis, infusions ofinfliximab, especially when given episodically, may result in thedevelopment of antibodies to infliximab, which in turn may lead toinfusion reactions, loss of efficacy, and delayed hypersensitivityreactions (Baert et al. N Engl J Med 2003;348:601-608; Cheifetz et al.Am J Gastroenterol 2003;98:1315-1324; Farrell et al. Gastroenterology2003;124:917-924; Hanauer et al. Gastroenterology 1999;116:A731; andHanauer et al. Clin Gastroenterol Hepatol 2004;2:542-553). In certaininstances, some patients who are administered a TNFα inhibitor for thetreatment of psoriasis and respond to said treatment, may eventuallylose their response to the first TNFα inhibitor. In other patientpopulations, intolerance to a certain TNFα inhibitor may be marked fromthe initial administration of the TNFα inhibitor. In one embodiment, theinvention provides use of a TNFα inhibitor in the manufacture of amedicament for treating psoriasis in a subject who has lost response toor is intolerant to a different TNFα inhibitor. In one embodiment, theTNFα inhibitor which the subject has lost response to or is intolerantto is infliximab or etanercept.

In one embodiment, the invention also provides methods and compositionsfor use in a subject who has not previously been administered a TNFinhibitor, such as infliximab or etanercept. Thus, in one embodiment,the methods and compositions of the invention are directed to asubpopulation of psoriasis patients who have not previously receivedinfliximab or etanercept.

In one embodiment, the invention provides an article of manufacturecomprising a human TNFα antibody, e.g., adalimumab and a package insert,wherein the package insert indicates that adalimumab may be used totreat psoriasis in patients who have had an inadequate response toconventional therapy and/or who have lost response to or are intolerantto infliximab or etanercept.

Articles of Manufacture

The invention also provides a packaged pharmaceutical compositionwherein the TNFα inhibitor, e.g., human TNFα antibody, is packagedwithin a kit or an article of manufacture. The kit or article ofmanufacture of the invention contains materials useful for thetreatment, including induction and/or remission, prevention and/ordiagnosis of psoriasis. The kit or article of manufacture comprises acontainer and a label or package insert or printed material on orassociated with the container which provides information regarding useof the TNFα inhibitor, e.g., a TNFα antibody, for the treatment ofpsoriasis.

A kit or an article of manufacture refers to a packaged productcomprising components with which to administer a TNFα inhibitor fortreatment of a psoriasis. The kit preferably comprises a box orcontainer that holds the components of the kit. The box or container isaffixed with a label or a Food and Drug Administration approved label,including a protocol for administering the TNFα inhibitor. The box orcontainer holds components of the invention which are preferablycontained within plastic, to polyethylene, polypropylene, ethylene, orpropylene vessels. The vessels can be capped-tubes or bottles. The kitcan also include instructions for administering the TNFα antibody of theinvention. In one embodiment the kit of the invention includes theformulation comprising the human antibody adalimumab (or D2E7), asdescribed in PCT/IB03/04502 and U.S. appln. Ser. No. 10/222140,incorporated by reference herein.

The term “package insert” is used to refer to instructions customarilyincluded in commercial packages of therapeutic products, that containinformation about the indications, usage, dosage, administration,contraindications and/or warnings concerning the use of such therapeuticproducts.

In one embodiment, the article of manufacture of the invention comprises(a) a first container with a composition contained therein, wherein thecomposition comprises a TNFα antibody; and (b) a package insertindicating that the TNFα antibody may be used for reducing signs andsymptoms and inducing and maintaining remission of psoriasis. In apreferred embodiment, the label or package insert indicates that theTNFα inhibitor, e.g., a TNFα antibody, is used for treating psoriasis.

Suitable containers for the TNFα inhibitor, e.g., a TNFα antibody,include, for example, bottles, vials, syringes, pens, etc. Thecontainers may be formed from a variety of materials such as glass orplastic. The container holds a composition which is by itself or whencombined with another composition effective for treating, preventingand/or diagnosing the condition and may have a sterile access port.

In one embodiment, the article of manufacture comprises a TNFαinhibitor, e.g., a human TNFα antibody, and a label or package insertwhich indicates to a subject who will be administering the TNFαinhibitor about using the TNFα inhibitor for the treatment of psoriasis.The label may be anywhere within or on the article of manufacture. Inone embodiment, the article of manufacture comprises a container, suchas a box, which comprises the TNFα inhibitor and a package insert orlabel providing information pertaining to use of the TNFα inhibitor forthe treatment of psoriasis. In another embodiment, the information isprinted on a label which is on the outside of the article ofmanufacture, in a position which is visible to prospective purchasers.

In one embodiment, the label or package insert of the invention informsa reader, including a subject, e.g., a purchaser, who will beadministering the TNFα inhibitor for treatment, that the TNFα inhibitor,e.g., a TNFα antibody such as adalimumab, is an indicated treatment ofpsoriasis, including of moderately to severely active disease in adultpatients.

In one embodiment, the label or package insert describes certain patientpopulations who may respond favorably to the TNFα inhibitor within thearticle of manufacture. For example, the label or package insert mayindicate that the TNFα antibody, e.g., adalimumab, may be used to treatpsoriasis in patients who have had to an inadequate response toconventional therapy and/or who have lost response to or are intolerantto infliximab or etanercept.

In one embodiment, the package insert of the invention informs a reader,including a subject, e.g., a purchaser, who will be administering theTNFα inhibitor for treatment, that the TNFα inhibitor, e.g., a TNFαantibody such as adalimumab, is an indicated treatment of psoriasis,including of moderately to severely active disease in adult patients whohave had an inadequate response to a previous biologic therapy and/orwho have lost response to or are intolerant to entanercept.

In another embodiment, the label of the invention indicates thatadalimumab is indicated for treatment of moderately to severely activepsoriasis in adult patients who have had an inadequate response to aprevious biologic therapy. In another embodiment, the label of theinvention indicates that the TNFα inhibitor, e.g., a TNFα antibody suchas adalimumab, is also indicated for treatment in adult patients withmoderately to severely active psoriasis who have lost response to or areintolerant to entanercept.

In one embodiment, the label or package insert of the inventiondescribes certain therapeutic benefits of the TNFα antibody, e.g.,adalimumab, including specific symptoms of psoriasis which may bereduced by using the TNFα antibody, e.g., adalimumab. It should be notedthat the package insert may also contain information pertaining to otherdisorders which are treatable using the TNFα antibody, e.g., adalimumab.Information described herein which is provided in a label or packageinsert and pertains to other disorders, i.e., diseases other thanpsoriasis, is also included within the scope of the invention. Thepackage insert of the invention may indicate that extra TNFα in yourbody can attack normal healthy body tissues and cause inflammationespecially in the tissues in your bones, cartilage, joints and digestivetract. The package insert of the invention may also indicate thatadalimumab helps reduce the signs and symptoms of immune diseases,including rheumatoid and psoriatic arthritis (pain and swollen joints),ankylosing spondylitis (morning stiffness and back pain), and psoriasis(abdominal pain and diarrhea).

In another embodiment, the package insert of the invention describes thedose and administration of adalimumab, for the treatment of psoriasis.The label may indicate that the initiation of therapy includes a 80 mgdose at week 0 and 40 mg at week 1. The label may also indicate that themaintenance dosing for the treatment of psoriasis with adalimumab is 40mg every other week. The label may also indicate that some patients withpsoriasis may derive additional benefit by increasing frequency to 40 mgevery week. In another embodiment, the label or package insert of theinvention indicates that adalimumab is administered by subcutaneousinjection.

In another embodiment, the label or the package insert of the inventionmay to indicate that the recommended TNFα inhibitor, e.g., a TNFαantibody such as adalimumab, dose regimen for adult patients withpsoriasis is 80 mg at week 0, followed by 40 mg every other weekbeginning at week 1. The label or package insert of the invention mayalso indicate that some patients may derive additional benefit fromincreasing the dosing frequency of the TNFα inhibitor, e.g., a TNFαantibody such as adalimumab from 40 mg every other week to 40 mg everyweek.

The label or the package insert of the invention may also provideinformation to subjects who will be receiving adalimumab regardingcombination uses for both safety and efficacy purposes. In anotherembodiment, the label or the package insert of the invention indicatesthat aminosalicylates, corticosteroids, and/or immunomodulatory agents(e.g., 6-mercaptopurine and azathioprine) may be continued duringtreatment with the TNFα inhibitor, e.g., a TNFα antibody, includingadalimumab. In one embodiment, the invention provides an article ofmanufacture comprising a packaging material; a TNFα antibody, orantigen-binding portion thereof; and a label or package insert containedwithin the packaging material indicating that aminosalicylates,corticosteroids, and/or immunomodulatory agent, e.g., 6-mercaptopurineand azathioprine, may be continued during treatment with the TNFαantibody, or antigen-binding portion thereof.

The label or the package insert of the invention may contain warningsand precautions regarding the use of the TNFα inhibitor, e.g., a TNFαantibody such as adalimumab. In one embodiment, the information providedin the label or the package insert describes malignancies.

The label or the package insert of the invention may contain informationregarding the use of the TNFα inhibitor, e.g., a TNFα antibody such asadalimumab, in clinical studies for psoriasis. In one embodiment, thelabel of the invention describes the studies described herein asExamples 1 to 23, either as a whole or in portion. The label of theinvention may also indicate that adalimumab has been studied in over1400 patients with psoriasis in four placebo-controlled and twoopen-label extension studies. The label of the invention may alsoindicate that the safety profile for patients with psoriasis treatedwith HUMIRA® was similar to the safety profile seen in patients withrheumatoid arthritis.

The label of the invention may contain information regarding thepharmacodynamics of the TNFα inhibitor, e.g., a TNFα antibody such asadalimumab. In one embodiment, the label of the invention indicates thatafter treatment with adalimumab, a rapid decrease in levels of acutephase reactants of inflammation (C-reactive protein (CRP) anderythrocyte sedimentation rate (ESR) and serum cytokines (IL-6) wasobserved compared to baseline in patients with rheumatoid arthritis. Inone embodiment, the label of the invention indicates that a rapiddecrease in CRP levels was to also observed in patients with psoriasis.The label may further indicate that serum levels of matrixmetalloproteinases (MMP-1 and MMP-3) that produce tissue remodelingresponsible for cartilage destruction were also decreased afteradalimumab administration.

In one embodiment of the invention, the kit comprises a TNFα inhibitor,such as an antibody, an second pharmaceutical composition comprising anadditional therapeutic agent, and instructions for administration ofboth agents for the treatment of psoriasis. The instructions maydescribe how, e.g., subcutaneously, and when, e.g., at week 0, week 2,and biweekly thereafter, doses of TNFα antibody and/or the additionaltherapeutic agent shall be administered to a subject for treatment.

Another aspect of the invention pertains to kits containing apharmaceutical composition comprising an anti-TNFα antibody and apharmaceutically acceptable carrier and one or more additionalpharmaceutical compositions each comprising a drug useful for treating aTNFα related disorder and a pharmaceutically acceptable carrier.Alternatively, the kit comprises a single pharmaceutical compositioncomprising an anti-TNFα antibody, one or more drugs useful for treatinga TNFα related disorder and a pharmaceutically acceptable carrier. Thekits further contain instructions for dosing of the pharmaceuticalcompositions for the treatment of a TNFα related disorder.

The package or kit alternatively may contain the TNFα inhibitor and itmay be promoted for use, either within the package or throughaccompanying information, for the uses or treatment of the disordersdescribed herein. The packaged pharmaceuticals or kits further caninclude a second agent (as described herein) packaged with or copromotedwith instructions for using the second agent with a first agent (asdescribed herein).

Additional Therapeutic Agents

TNFα inhibitors, including TNFα antibodies, or antigen binding portionsthereof, may be used in the methods, uses, and compositions of theinvention either alone or in combination with an additional therapeuticagent. It should be understood that the TNFα inhibitors can be usedalone or in combination with an additional agent, e.g., a therapeuticagent, said additional agent being selected by the skilled artisan forits intended purpose. For example, the additional agent can be atherapeutic agent art-recognized as being useful to treat the disease orcondition being treated by the TNFα inhibitors. The additional agentalso can be an agent that imparts a beneficial attribute to thetherapeutic composition, e.g., an agent which effects the viscosity ofthe composition.

It should further be understood that the combinations which are to beincluded within this invention are those combinations useful for theirintended purpose. The to agents set forth below are illustrative forpurposes and not intended to be limited. The combinations, which arepart of this invention, can be the TNFα inhibitors of the presentinvention and at least one additional agent selected from the listsbelow. The combination can also include more than one additional agent,e.g., two or three additional agents if the combination is such that theformed composition can perform its intended function.

Non-limiting examples of therapeutic agents for Psoriasis with which anantibody, or antibody portion, of the invention can be combined includethe following: small molecule inhibitor of KDR (ABT-123), small moleculeinhibitor of Tie-2, calcipotriene, clobetasol propionate, triamcinoloneacetonide, halobetasol propionate, tazarotene, methotrexate,fluocinonide, betamethasone diprop augmented, fluocinolone acetonide,acitretin, tar shampoo, betamethasone valerate, mometasone furoate,ketoconazole, pramoxine/fluocinolone, hydrocortisone valerate,flurandrenolide, urea, betamethasone, clobetasol propionate/emoll,fluticasone propionate, azithromycin, hydrocortisone, moisturizingformula, folic acid, desonide, pimecrolimus, coal tar, diflorasonediacetate, etanercept folate, lactic acid, methoxsalen, he/bismuthsubgal/znox/resor, methylprednisolone acetate, prednisone, sunscreen,halcinonide, salicylic acid, anthralin, clocortolone pivalate, coalextract, coal tar/salicylic acid, coal tar/salicylic acid/sulfur,desoximetasone, diazepam, emollient, fluocinonide/emollient, mineraloil/castor oil/na lact, mineral oil/peanut oil, petroleum/isopropylmyristate, psoralen, salicylic acid, soap/tribromsalan, thimerosal/boricacid, celecoxib, infliximab, cyclosporine, alefacept, efalizumab,tacrolimus, pimecrolimus, PUVA, UVB, sulfasalazine.

TNFα inhibitors described herein may be used in combination withadditional therapeutic agents such as a Disease Modifying Anti-RheumaticDrug (DMARD) or a Nonsteroidal Antiinflammatory Drug (NSAID) or asteroid or any combination thereof. Preferred examples of a DMARD arehydroxychloroquine, leflunomide, methotrexate, parenteral gold, oralgold and sulfasalazine. Preferred examples of non-steroidalanti-inflammatory drug(s) also referred to as NSAIDS include drugs likeibuprofen. Other preferred combinations are corticosteroids includingprednisolone; the well known side effects of steroid use can be reducedor even eliminated by tapering the steroid dose required when treatingpatients in combination with TNFα inhibitors of this invention.

Preferred combinations of therapeutic agents may interfere at differentpoints in the autoimmune and subsequent inflammatory cascade; preferredexamples include TNF antagonists such as soluble p55 or p75 TNFreceptors, derivatives, thereof, (p75TNFR1gG (Enbrel™) or p55TNFR1gG(Lenercept), chimeric, humanized or human TNF antibodies, or a fragmentthereof, including infliximab (Remicade®, Johnson and Johnson; describedin U.S. Pat. No. 5,656,272, incorporated by reference to herein),PSORIASIS P571 (a humanized monoclonal anti-TNF-alpha IgG4 antibody),PSORIASIS P 870 (a humanized monoclonal anti-TNF-alpha antibodyfragment), an anti-TNF dAb (Peptech), CNTO 148 (golimumab; Medarex andCentocor, see WO 02/12502), and adalimumab (HUMIRA®^(®) AbbottLaboratories, a human anti-TNF mAb, described in U.S. Pat. No. 6,090,382as D2E7). Additional TNF antibodies which can be used in the inventionare described in U.S. Pat. Nos. 6,593,458; 6,498,237; 6,451,983;

and 6,448,380, each of which is incorporated by reference herein. Othercombinations including TNFα converting enzyme (TACE) inhibitors; IL-1inhibitors (Interleukin-1-converting enzyme inhibitors, IL-1RA etc.) maybe effective for the same reason. Other preferred combinations includeInterleukin 11. Yet another preferred combination are other key playersof the autoimmune response which may act parallel to, dependent on or inconcert with TNFα inhibitors function; especially preferred are IL-18antagonists including IL-18 antibodies or soluble IL-18 receptors, orIL-18 binding proteins. Yet another preferred combination arenon-depleting anti-PSORIASIS 4 inhibitors. Yet other preferredcombinations include antagonists of the co-stimulatory pathway PSORIASIS80 (B7.1) or PSORIASIS 86 (B7.2) including antibodies, soluble receptorsor antagonistic ligands.

The TNFα inhibitors used in the invention may also be combined withagents, such as methotrexate, 6-MP, azathioprine sulphasalazine,mesalazine, olsalazine chloroquinine/hydroxychloroquine, pencillamine,aurothiomalate (intramuscular and oral), azathioprine, cochicine,corticosteroids (oral, inhaled and local injection), beta-2adrenoreceptor agonists (salbutamol, terbutaline, salmeteral), xanthines(theophylline, aminophylline), cromoglycate, nedocromil, ketotifen,ipratropium and oxitropium, cyclosporin, FK506, rapamycin, mycophenolatemofetil, leflunomide, NSAIDs, for example, ibuprofen, corticosteroidssuch as prednisolone, phosphodiesterase inhibitors, adensosine agonists,antithrombotic agents, complement inhibitors, adrenergic agents, agentswhich interfere with signalling by proinflammatory cytokines such asTNFα or IL-1 (e.g. IRAK, NIK, IKK , p38 or MAP kinase inhibitors), IL-1βconverting enzyme inhibitors, TNFα converting enzyme (TACE) inhibitors,T-cell signalling inhibitors such as kinase inhibitors,metalloproteinase inhibitors, sulfasalazine, azathioprine,6-mercaptopurines, angiotensin converting enzyme inhibitors, solublecytokine receptors and derivatives thereof (e.g. soluble p55 or p75 TNFreceptors and the derivatives p75TNFRIgG (Enbrel™ and p55TNFRIgG(Lenercept)), sIL-1RI, sIL-1RII, sIL-6R), antiinflammatory cytokines(e.g. IL-4, IL-10, IL-11, IL-13 and TGFβ), celecoxib, folic acid,hydroxychloroquine sulfate, rofecoxib, etanercept, infliximab, naproxen,valdecoxib, sulfasalazine, methylprednisolone, meloxicam,methylprednisolone acetate, gold sodium thiomalate, aspirin,triamcinolone acetonide, propoxyphene napsylate/apap, folate,nabumetone, diclofenac, piroxicam, etodolac, diclofenac sodium,oxaprozin, oxycodone hcl, hydrocodone bitartrate/apap, diclofenacsodium/misoprostol, fentanyl, anakinra, human recombinant, tramadol hcl,salsalate, sulindac, cyanocobalamin/fa/pyridoxine, acetaminophen,alendronate sodium, prednisolone, morphine sulfate, lidocainehydrochloride, indomethacin, glucosamine sulf/chondroitin, amitriptylinehcl, sulfadiazine, oxycodone hcl/acetaminophen, olopatadine hcl,misoprostol, naproxen sodium, omeprazole, cyclophosphamide, rituximab,IL-1 TRAP, MRA, CTLA4-IG, IL-18 BP, anti-IL-18, Anti-IL15, BIRB-796,SCIO-469, VX-702, AMG-548, VX-740, Roflumilast, IC-485, PSORIASIS C-801,and Mesopram.

Non-limiting examples of therapeutic agents for psoriasis with whichTNFα inhibitor of the invention can be combined include the following:budenoside; epidermal growth factor; corticosteroids; cyclosporin,sulfasalazine; aminosalicylates; 6-mercaptopurine; azathioprine;metronidazole; lipoxygenase inhibitors; mesalamine; olsalazine;balsalazide; antioxidants; thromboxane inhibitors; IL-1 receptorantagonists; anti-IL-1β monoclonal antibodies; anti-IL-6 monoclonalantibodies; growth factors; elastase inhibitors; pyridinyl-imidazolecompounds; antibodies to or antagonists of other human cytokines orgrowth factors, for example, TNF, LT, IL-1, IL-2, IL-6 (includingActemra (tocilizumab), IL-7, IL-8, IL-15, IL-16, IL-17, IL-18, EMAP-II,GM-CSF, FGF, and PDGF. Antibodies of the invention, or antigen bindingportions thereof, can be combined with antibodies to cell surfacemolecules such as CD2, CD3, CD4, CD8, CD25, CD28, CD30, CD40, CD45,CD69, CD80 (B7.1), CD86 (B7.2), CD90, CTLA or their ligands includingCD154 (gp39 or CD4OL).

The antibodies of the invention, or antigen binding portions thereof,may also be combined with agents, such as methotrexate, cyclosporin,FK506, rapamycin, mycophenolate mofetil, leflunomide, NSAIDs, forexample, ibuprofen, corticosteroids such as prednisolone,phosphodiesterase inhibitors, adenosine agonists, antithrombotic agents,complement inhibitors, adrenergic agents, agents which interfere withsignalling by proinflammatory cytokines such as TNFα or IL-1 (e.g. IRAK,NIK, IKK, p38 or MAP kinase inhibitors), IL-1β converting enzymeinhibitors, TNFα converting enzyme inhibitors, T-cell signallinginhibitors such as kinase inhibitors, metalloproteinase inhibitors,sulfasalazine, azathioprine, 6-mercaptopurines, angiotensin convertingenzyme inhibitors, soluble cytokine receptors and derivatives thereof(e.g. soluble p55 or p75 TNF receptors, sIL-1RI, sIL-1RII, sIL-6R) andantiinflammatory cytokines (e.g. IL-4, IL-10, IL-11, IL-13 and TGFβ).

Additional examples of therapeutic agents for psoriasis in which a TNFαinhibitor can be combined include the following: combinations of TNFantagonists, for example, anti-TNF antibodies, D2E7 (PCT Publication No.WO 97/29131; HUMIRA®), CA2 (REMICADE), PSORIASIS P 571, TNFR-Igconstructs, (p75TNFRIgG (ENBREL) and p55TNFRIgG (LENERCEPT)) inhibitorsand PDE4 inhibitors. TNFα to inhibitors of the invention can be combinedwith corticosteroids, for example, budenoside and dexamethasone. TNFαinhibitors of the invention may also be combined with agents such assulfasalazine, 5-aminosalicylic acid and olsalazine, and agents whichinterfere with synthesis or action of proinflammatory cytokines such asIL-1, for example, IL-1β converting enzyme inhibitors and IL-lra. TNFαinhibitors may also be used with T cell signaling inhibitors, forexample, tyrosine kinase inhibitors 6-mercaptopurines. TNFα inhibitorscan be combined with IL-11. TNFα inhibitors can be combined withmesalamine, prednisone, azathioprine, mercaptopurine, infliximab,methylprednisolone sodium succinate, diphenoxylate/atrop sulfate,loperamide hydrochloride, methotrexate, omeprazole, folate,ciprofloxacin/dextrose-water, hydrocodone bitartrate/apap, tetracyclinehydrochloride, fluocinonide, metronidazole, thimerosal/boric acid,cholestyramine/sucrose, ciprofloxacin hydrochloride, hyoscyaminesulfate, meperidine hydrochloride, midazolam hydrochloride, oxycodonehcl/acetaminophen, promethazine hydrochloride, sodium phosphate,sulfamethoxazole/trimethoprim, celecoxib, polycarbophil, propoxyphenenapsylate, hydrocortisone, multivitamins, balsalazide disodium, codeinephosphate/apap, colesevelam hcl, cyanocobalamin, folic acid,levofloxacin, methylprednisolone, natalizumab and interferon-gamma

The TNFα inhibitors may also be combined with agents, such asalemtuzumab, dronabinol, Unimed, daclizumab, mitoxantrone, xaliprodenhydrochloride, fampridine, glatiramer acetate, natalizumab, sinnabidol,a-immunokine NNSO3, ABR-215062, AnergiX.MS, chemokine receptorantagonists, BBR-2778, calagualine, CPI-1189, LEM (liposome encapsulatedmitoxantrone), THC.CBD (cannabinoid agonist) MBP-8298, mesopram (PDE4inhibitor), MNA-715, anti-IL-6 receptor antibody, neurovax, pirfenidoneallotrap 1258 (RDP-1258), sTNF-R1, talampanel, teriflunomide,TGF-beta2,tiplimotide, VLA-4 antagonists (for example, TR-14035, VLA4 Ultrahaler,Antegran-ELAN/Biogen), interferon gamma antagonists, IL-4 agonists, andthe humanized IL-6 antibody tocilizumab.

In yet another embodiment, the invention includes an article ofmanufacture or a method comprising the combination of a TNF inhibitorand an antibiotic or antiinfective agent. Antiinfective agents includethose agents known in the art to treat viral, fungal, parasitic orbacterial infections. The term, “antibiotic,” as used herein, refers toa chemical substance that inhibits the growth of, or kills,microorganisms. Encompassed by this term are antibiotic produced by amicroorganism, as well as synthetic antibiotics (e.g., analogs) known inthe art. Antibiotics include, but are not limited to, clarithromycin(Biaxin®), ciprofloxacin (Cipro®), and metronidazole (Flagyl®).

Any one of the above-mentioned therapeutic agents, alone or incombination therewith, can be administered to a subject suffering from aTNFα-related disorder in to which TNFα is detrimental, in combinationwith the TNFα antibody using a multiple variable dose treatment regimen.In one embodiment, any one of the above-mentioned therapeutic agents,alone or in combination therewith, can be administered to a subjectsuffering from an intestinal disorder in addition to a TNFα antibody totreat another TNFα-related disorder, such as rheumatoid arthritis. Itshould be understood that the additional therapeutic agents can be usedin combination therapy as described above, but also may be used in otherindications described herein wherein a beneficial effect is desired.

The combination of agents used within the methods and pharmaceuticalcompositions described herein may have a therapeutic additive orsynergistic effect on the condition(s) or disease(s) targeted fortreatment. The combination of agents used within the methods orpharmaceutical compositions described herein also may reduce adetrimental effect associated with at least one of the agents whenadministered alone or without the other agent(s) of the particularpharmaceutical composition. For example, the toxicity of side effects ofone agent may be attenuated by another agent of the composition, thusallowing a higher dosage, improving patient compliance, and improvingtherapeutic outcome. The additive or synergistic effects, benefits, andadvantages of the compositions apply to classes of therapeutic agents,either structural or functional classes, or to individual compoundsthemselves.

IV. Efficacy of TNFα Inhibitor

The invention provides methods for determining whether a TNFα inhibitoris effective at treating a skin disorder associated with detrimentalTNFα activity, such as psoriasis, in a subject who has a subtherapeuticresponse to a therapy, who has failed to respond to a therapy, or haslost responsiveness to a therapy. Such methods may be used to determinethe efficacy of a TNFα inhibitor, including those which are unknown orunconfirmed to have such efficacy. Using the methods described herein,effective TNFα inhibitors may be determined or confirmed, and,subsequently, used in the method of treating psoriasis. Further methodsfor determining whether a TNFα inhibitor is effective at treatingpsoriasis in a subject are described in U.S. Provisional ApplicationNos. 60/832370 (filed Jul. 20, 2006), 60/851830 (filed Oct. 6, 2006),and 60/857352 (filed Nov. 6, 2006), each of which are incorporatedherein by reference.

Patient populations described in the methods of the invention aregenerally selected based on common characteristics In one non-limitingexample, the patient population contains subjects diagnosed withpsoriasis who are in remission as a result of being on a dosing regimencomprising a TNFα. Such a patient population would be appropriate fordetermining the efficacy of the TNFα inhibitor for maintaining remissionin psoriasis in the given patient population. In another embodiment, thepatient population contains subjects who have a subtherapeutic responseto a biologic therapy, who have failed to respond to a biologic therapy,or have lost responsiveness to a biologic therapy, such as etanercept.In one embodiment, the patient population contains subjects who havefailed to respond or lost responsiveness to a biologic TNFα inhibitor(e.g., entanercept). In a related embodiment, the patient population isan adult population, e.g., older than 17 years of age or older than 18years of age.

In one embodiment, the article of manufacture of the invention comprisesinstructions regarding how to determine the efficacy of the TNFinhibitor for the treatment of psoriasis. In one embodiment, the articleof manufacture of the invention comprises instructions regarding how todetermine the efficacy of the TNF inhibitor for the treatment ofpsoriasis in patients who has a subtherapeutic response to a biologictherapy, who has failed to respond to a biologic therapy, or has lostresponsiveness to a biologic therapy, such as entanercept.

The invention also provides methods for determining whether a TNFαinhibitor is effective at treating psoriasis in a subject. Such methodsmay be used to determine the efficacy of a TNFα inhibitor, includingthose which are unknown or unconfirmed to have such efficacy. Using themethods described herein, effective TNFα inhibitors may be determined orconfirmed, and, subsequently, used in the method of treating psoriasis.

The PASI, PGA, and DLQI scores may be used as an index for measuringefficacy of a TNFα inhibitor in a subject or patient population havingpsoriasis, where attaining a certain percentage of patients within apopulation who were administered the TNFα inhibitor and who maintainclinical remission, i.e. PASI <50 or PASI <75, indicates that the TNFαinhibitor is effective for treating of psoriasis. In one embodiment, theinvention provides a method for determining whether a human TNFαantibody is effective for treating psoriasis.

The efficacy of a TNFα inhibitor for treating psoriasis in a patientpopulation, e.g., PASI 75 response (also referred to herein as aPASI/PASI75 score), may be evaluated by determining the percentage ofthe patient population in treatment of psoriasis has been effectivefollowing administration of the TNFα inhibitor.

In one embodiment, a PASI 50 response is achieved in at least about 57%of the patient population indicates that the human TNFα antibody is aneffective human TNFα antibody for the treatment of psoriasis in asubject. In one embodiment, a PASI 50 response is achieved in at leastabout 65% of the patient population indicates that the human TNFαantibody is an effective human TNFα antibody for the treatment ofpsoriasis in a subject. In one embodiment, a PASI50 response is achievedin at least about 70% of the patient population indicates that the humanTNFα antibody is an effective human TNFα antibody for the treatment ofpsoriasis in a subject. In one embodiment, a PASI 50 response isachieved in at least about 75% of the patient to population indicatesthat the human TNFα antibody is an effective human TNFα antibody for thetreatment of psoriasis in a subject. In one embodiment, a PASI 50response is achieved in at least about 80% of the patient populationindicates that the human TNFα antibody is an effective human TNFαantibody for the treatment of psoriasis in a subject. In one embodiment,a PASI 50 response is achieved in at least about 85% of the patientpopulation indicates that the human TNFα antibody is an effective humanTNFα antibody for the treatment of psoriasis in a subject. In oneembodiment, a PASI 50 response is achieved in at least about 92% of thepatient population indicates that the human TNFα antibody is aneffective human TNFα antibody for the treatment of psoriasis in asubject.

Numbers intermediate to the above recited percentages, e.g., 57%, 58%,59%, 60%, 61%, 62%, 63%, 64%, 65%, 66%, 67%, 68%, 69%, 70%, 71%, 72%,73%, 74%, 75%, 76%, 77%, 78%, 79%, 80%, 81%, 82%, 83%, 84%, 85%, 86%,87%, 88%, 89%, 90%, 91%, 92%, as well as all other numbers recitedherein, are also intended to be part of this invention. Ranges of valuesusing a combination of any of the above recited values as upper and/orlower limits are intended to be included in the scope of the invention.For example, in one embodiment a PASI 50 response score of in at leastbetween 59% and 90% of the patient population indicates that the TNFαinhibitor is an effective TNFα inhibitor for the treatment of psoriasisin a subject.

In one embodiment, the invention provides a method of determining theefficacy of a TNFα inhibitor for treating psoriasis in a subjectcomprising determining a Psoriasis Area Severity Index (PASI) score of apatient population having psoriasis and who was administered the TNFαinhibitor, wherein a PASI 75 response is achieved in at least about 77%of the patient population indicates that the TNFα inhibitor is aneffective TNFα inhibitor for the treatment of psoriasis in a subject. Inone embodiment, the method further comprises administering the effectiveTNFα inhibitor to a subject to treat psoriasis. The invention provides amethod of treatingpsoriasis in a subject comprising administering aneffective amount of a TNFα inhibitor to the subject such that treatmentof psoriasis is maintained, wherein the effective human TNFα antibodywas previously identified as achieving a PASI 75 response in at leastabout 62% of a patient population having psoriasis and a baseline PASIgreater than 10.

In one embodiment, the invention provides a method of treatnig psoriasisin a subject comprising administering an effective amount of a humanTNFα antibody to the subject such that psoriasis is treated, wherein theeffective human TNFα antibody was previously identified as achieving aPASI 75 response in at least about 62% of a patient population havingpsoriasis and a baseline PASI greater than 10.

In one embodiment, a PASI 75 response is achieved in at least about 23%of the patient population indicates that the human TNFα antibody is aneffective human to TNFα antibody for the treatment of psoriasis in asubject. In one embodiment, a PASI 75 response is achieved in at leastabout 45% of the patient population indicates that the human TNFαantibody is an effective human TNFα antibody for the treatment ofpsoriasis in a subject. In one embodiment, a PASI 75 response isachieved in at least about 64% of the patient population indicates thatthe human TNFα antibody is an effective human TNFα antibody for thetreatment of psoriasis in a subject. In one embodiment, a PASI 75response is achieved in at least about 75% of the patient populationindicates that the human TNFα antibody is an effective human TNFαantibody for the treatment of psoriasis in a subject. In one embodiment,a PASI 75 response is achieved in at least about 82% of the patientpopulation indicates that the human TNFα antibody is an effective humanTNFα antibody for the treatment of psoriasis in a subject. In oneembodiment, the method further comprises administering the effectiveTNFα inhibitor to a subject to treat psoriasis.

Numbers intermediate to the above recited percentages, e.g., 20%, 21%,22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31%, 32%, 33%, 34%. 35%,36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%,50%, 51%, 52%, 53%, 54%, 55%, 56%, 57%, 58%, 59%, 60%, 61%, 62%, 63%,64%, 65%, 66%, 67%, 68%, 69%, 70%, 71%, 72%, 73%, 74%, 75%, 76%, 77%,78%, 79%, 80%. 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, and 89%, as wellas all other numbers recited herein, are also intended to be part ofthis invention. Ranges of values using a combination of any of the aboverecited values as upper and/or lower limits are intended to be includedin the scope of the invention. For example, in one embodiment a PASI 75response score of in at least between 35% and 81% of the patientpopulation indicates that the TNFα inhibitor is an effective TNFαinhibitor for the treatment of psoriasis in a subject.

The invention provides a method of treating psoriasis in a subjectcomprising administering an effective amount of a TNFα inhibitor to thesubject such that treatment of psoriasis is maintained, wherein theeffective human TNFα antibody was previously identified as achieving aPASI 75 response in at least about 23% of a patient population havingpsoriasis.

In one embodiment the invention provides a method of determining theefficacy of a TNFα inhibitor for treating psoriasis in a subjectcomprising determining a PASI 90 response of a patient population havingpsoriasis who was administered the human TNFα antibody, wherein a PASI90 response is achieved in at least about 27% of the patient populationindicates that the human TNFα antibody is an effective human TNFαantibody for treating psoriasis in a subject.

In one embodiment, a PASI 90 response is achieved in at least about 27%of the patient population indicates that the human TNFα antibody is aneffective human TNFα antibody for achieving a clinical response inpsoriasis in a subject. In one to embodiment, a PASI 90 response isachieved in at least about 39% of the patient population indicates thatthe human TNFα antibody is an effective human TNFα antibody forachieving a clinical response in psoriasis in a subject. In oneembodiment, a PASI 90 response is achieved in at least about 48% of thepatient population indicates that the human TNFα antibody is aneffective human TNFα antibody for achieving a clinical response inpsoriasis in a subject. In one embodiment, a PASI 90 response isachieved in at least about 52% of the patient population indicates thatthe human TNFα antibody is an effective human TNFα antibody forachieving a clinical resppnse in psoriasis in a subject. In oneembodiment, a PASI 90 response is achieved in at least about 58% of thepatient population indicates that the human TNFα antibody is aneffective human TNFα antibody for achieving a clinical response inpsoriasis in a subject. In one embodiment, a PASI 90 response isachieved in at least about 62% of the patient population indicates thatthe human TNFα antibody is an effective human TNFα antibody forachieving a clinical response in psoriasis in a subject.

Numbers intermediate to the above recited percentages, e.g., 27%, 28%,29%, 30%, 31%, 32%, 33%, 34%. 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%,43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%,57%, 58%, 59%, 60%, 61%, 62%, as well as all other numbers recitedherein, are also intended to be part of this invention. Ranges of valuesusing a combination of any of the above recited values as upper and/orlower limits are intended to be included in the scope of the invention.For example, in one embodiment a PASI 90 response score of in at leastbetween 31% and 49% of the patient population indicates that the TNFαinhibitor is an effective TNFα inhibitor for the treatment of psoriasisin a subject.

In one embodiment the invention provides a method of determining theefficacy of a TNFα inhibitor for treating psoriasis in a subjectcomprising determining a PASI 100 response of a patient populationhaving psoriasis who was administered the human TNFα antibody, wherein aPASI 100 response is achieved in at least about 11% of the patientpopulation indicates that the human TNFα antibody is an effective humanTNFα antibody for treating psoriasis in a subject.

In one embodiment, a PASI 100 response is achieved in at least about 11%of the patient population indicates that the human TNFα antibody is aneffective human TNFα antibody for achieving a clinical response inpsoriasis in a subject. In one embodiment, a PASI 100 response isachieved in at least about 14% of the patient population indicates thatthe human TNFα antibody is an effective human TNFα antibody forachieving a clinical response in psoriasis in a subject. In oneembodiment, a PASI 100 response is achieved in at least about 20% of thepatient to population indicates that the human TNFα antibody is aneffective human TNFα antibody for achieving a clinical response inpsoriasis in a subject. In one embodiment, a PASI 100 response isachieved in at least about 22% of the patient population indicates thatthe human TNFα antibody is an effective human TNFα antibody forachieving a clinical response in psoriasis in a subject. In oneembodiment, a PASI 100 response is achieved in at least about 32% of thepatient population indicates that the human TNFα antibody is aneffective human TNFα antibody for achieving a clinical response inpsoriasis in a subject.

Numbers intermediate to the above recited percentages, e.g., 11%, 12%,13%, 14%, 15%, 16%, 17%, 18%, 19%, 20%, 21%, 22%, 23%, 24%, 25%, 26%,27%, 28%, 29%, 30%, 31%, 32%,as well as all other numbers recitedherein, are also intended to be part of this invention. Ranges of valuesusing a combination of any of the above recited values as upper and/orlower limits are intended to be included in the scope of the invention.For example, in one embodiment a PASI 100 response of between 11% and19% of the patient population indicates that the TNFα inhibitor is aneffective TNFα inhibitor for the treatment of psoriasis in a subject.

In one embodiment the invention provides a method of determining theefficacy of a TNFα inhibitor for achieving a clinical response inpsoriasis in a subject comprising determining a Physician's GlobalAssessment (PGA) score of a patient population having psoriasis who wasadministered the human TNFα antibody, wherein a PGA score of “clear” or“almost clear” in at least about 27% of the patient population indicatesthat the human TNFα antibody is an effective human TNFα antibody fortreating psoriasis in a subject.

In one embodiment, the invention provides a method of treating psoriasisin a subject comprisign administering an effective amount of a humanTNFα antibody to the subject, wherein the effective human TNFα antibodywas previously identified as maintaining a PGA score of “clear” or“almost clear” in at least about 27% of a patient population havingpsoriasis.

In one embodiment, a PGA score of “clear” or “almost clear” in at leastabout 27% of a patient population having psoriasis indicates that thehuman TNFα antibody is an effective human TNFα antibody for treatingpsoriasis in a subject. In one embodiment, a PGA score of “clear” or“almost clear” in at least about 33% of a patient population havingpsoriasis indicates that the human TNFα antibody is an effective humanTNFα antibody for treating psoriasis in a subject. In one embodiment, aPGA score of “clear” or “almost clear” in at least about 48% of apatient population having psoriasis indicates that the human TNFαantibody is an effective human TNFα antibody for treating psoriasis in asubject. In one embodiment, a PGA score of “clear” or “almost clear” inat least about 52% of a patient population having psoriasis indicatesthat the human TNFα antibody is an effective human TNFα antibody fortreating psoriasis in a subject. In one embodiment, a PGA score of“clear” or “almost clear” in at least about 66% of a patient populationhaving psoriasis indicates that the human TNFα antibody is an effectivehuman TNFα antibody for treating psoriasis in a subject. . In oneembodiment, a PGA score of “clear” or “almost clear” in at least about81% of a patient population having psoriasis indicates that the humanTNFα antibody is an effective human TNFα antibody for treating psoriasisin a subject.

Numbers intermediate to the above recited percentages, e.g., 27%, 28%,29%, 30%, 31%, 32%, 33%, 34%. 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%,43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%,57%, 58%, 59%, 60%, 61%, 62%, 63%, 64%, 65%, 66%, 67%, 68%, 69%, 70%,71%, 72%, 73%, 74%, 75%, 76%, 77%, 78%, 79%, 80%. 81%, as well as allother numbers recited herein, are also intended to be part of thisinvention. Ranges of values using a combination of any of the aboverecited values as upper and/or lower limits are intended to be includedin the scope of the invention. For example, in one embodiment a PGAscore of “clear” or “almost clear” in at least between 77% and 90% ofthe patient population indicates that the TNFα inhibitor is an effectiveTNFα inhibitor for the treatment of psoriasis in a subject.

In one embodiment the invention provides a method of determining theefficacy of a TNFα inhibitor for achieving a clinical response inpsoriasis in a subject comprising determining a DLQI score of a patientpopulation having psoriasis who was administered the human TNFαantibody, wherein a DLQI score of no or small impact in at least about67% of the patient population indicates that the human TNFα antibody isan effective human TNFα antibody for treating psoriasis in a subject. Inone embodiment, a DLQI score of no or small impact in at least about 85%of the patient population indicate efficacy. Numbers intermediate to theabove recited percentages, e.g., 67%, 68%, 69%, 70%, 71%, 72%, 73%, 74%,75%, 76%, 77%, 78%, 79%, 80%. 81%, 82%, 83%, 84%, and 85%, as well asall other numbers recited herein, are also intended to be part of thisinvention. Ranges of values using a combination of any of the aboverecited values as upper and/or lower limits are intended to be includedin the scope of the invention. For example, in one embodiment a DLQIscore of no or small impact in at least between 68% and 76% of thepatient population indicates that the TNFα inhibitor is an effectiveTNFα inhibitor for the treatment of psoriasis in a subject.

It should be noted that the Examples provided herein represent differentmethods of determining the efficacy of a TNFα inhibitor, such as a humanTNFα antibody, or antigen-binding portion thereof. As such, data andresults described in the Examples section which shows efficacy of a TNFαinhibitor, e.g., ability to maintain remission of to psoriasis, areincluded in the methods of determining efficacy of the invention.

Time points for determining efficacy will be understood by those ofskill in the art to depend on the type of efficacy being determined,e.g., treatment of psoriasis. In one embodiment, measurements in scores,e.g., the PASI response or PGA score of a subject, may be measuredagainst a subject's baseline score. Generally, a baseline refers to ameasurement or score of a patient before treatment, i.e. week 0. Othertime points may also be included as a starting point in determiningefficacy, however.

Patient populations described in the methods of the invention aregenerally selected based on common characteristics, such as, but notlimited to, subjects diagnosed with psoriasis, e.g., certain PASI score.Such a patient population would be appropriate for determining theefficacy of the TNFα inhibitor for treating psoriasis in the givenpatient population. In one embodiment, the patient population is anadult population, e.g., older than 17 years of age or older than 18years of age.

In one embodiment, the methods of the invention for determining whethera TNFα inhibitor is an effective TNFα inhibitor, include determiningchanges, improvements, measurements, etc., in psoriasis usingappropriate indices known in the art, e.g., PASI, PGA, DLQI, status ofpsoriasis related disorders, etc. from a patient population who hasalready been administered the TNFα inhibitor. Such a patient populationmay be pre-selected according to common characteristics, e.g., PASIscore, and may have already been given the TNFα inhibitor.Administration of the TNFα inhibitor may or may not be performed by thesame person of ordinary skill who is determining the efficacy of theTNFα inhibitor in accordance with the teachings of the specification.

In one embodiment, the methods of the invention comprise administeringthe TNFα inhibitor to the subjects of a patient population anddetermining the efficacy of the TNFα inhibitor by determining changes,improvements, measurements, etc., using psoriasis indices known in theart, in the patient population in comparison to the Examples set forthbelow. For example, in one embodiment the invention includes a methodfor determining efficacy of a TNFα inhibitor for the treatment ofpsoriasis comprising administering the TNFα inhibitor to a preselectedpatient population having psoriasis; and determining the effectivenessof the TNFα inhibitor by using a mean baseline Psoriasis Area SeverityIndex (PASI) response of the patient population and a mean PASI responsefollowing administration of the TNFα inhibitor, wherein a PASI 75response achieved in at least about 45% of the patient populationindicates that the TNFα inhibitor is effective for the treatment ofpsoriasis.

In addition, while the above methods are described in terms of patientpopulations, methods of efficacy described herein may also be applied toindividual subjects. For example, a method for determining efficacy maycomprise determining to whether a subject who has psoriasis, and who ison a dosage regimen comprising a human TNFα antibody, is able to achievea PASI 75 response to determing if the human TNFα antibody is aneffective human TNFα antibody. In one embodiment, if the subject is ableto achieve a PASI 75 response for at least about 24 weeks, then thehuman TNFα antibody is effective at treating psoriasis.

The Examples and discoveries described herein are representative of aTNFα inhibitor, i.e., adalimumab, which is effective for treatingpsoriasis. As such, the studies and results described in the Examplessection herein may be used as a guideline for determining the efficacyof a TNFα inhibitor, i.e., whether a TNFα inhibitor is an effective TNFαinhibitor for the treatment of psoriasis. In one embodiment, methods ofdetermining efficacy described herein may be used to determine whether aTNFα inhibitor is bioequivalent to another TNFα inhibitor.

Some of the Examples and discoveries described herein are representativeof a TNFα inhibitor, i.e., adalimumab, which is effective for treatingpsoriasis, including inducing and maintaining remission of psoriasis inpatients who has a subtherapeutic response to a biologic therapy, whohas failed to respond to a biologic therapy, or has lost responsivenessto a biologic therapy, such as entanercept. As such, the studies andresults described in the Examples section herein may be used as aguideline for determining the efficacy of a TNFα inhibitor, i.e.,whether a TNFα inhibitor is an effective TNFα inhibitor for thetreatment of psoriasis for subjects in this patient population.

The present invention is further illustrated by the following exampleswhich should not be construed as limiting in any way.

EXAMPLES Example 1: Rapid Improvement in Functional Limitations ofPatients with Moderate to Severe Chronic Plaque Psoriasis Treated withAdalimumab

Psoriasis affects approximately 1-3% of the worldwide population.Moderate to severe disease is associated with psoriatic lesions on >3%body surface area. Clinical manifestations of moderate to severepsoriasis can severely limit a patient's physical function.

Efficacy and safety of adalimumab was evaluated in a 48-week extensiontrial conducted at eighteen sites. The study was a randomized,double-blind, placebo-controlled, multi-center clinical trial, whereinpatients were randomized to one of three treatment groups. The threetreatment groups consisted of the following:

-   -   1. 80 mg adalimumab at baseline (week 0) and 40 mg at week 1        followed by 40 mg every other week (eow) starting at week 3        (referred to as ada 40 mg eow);    -   2. 80 mg adalimumab at baseline (week 0) and 80 mg at week 1        followed by 40 mg weekly starting at week 2 (referred to as ada        40 mg weekly); or    -   3. placebo administered weekly beginning at baseline (referred        to as placebo).        Inclusion criteria included a diagnosis of moderate to severe        chronic plaque psoriasis >1 year prior to entry, a        psoriasis-affected body surface area (BSA) >5%, and no previous        use of TNF-antagonist therapy.

A total of 142 patients who completed the 12 week randomized trialenrolled in the extension trial. Patients initially randomized to activetreatment continued on their assigned dose. Placebo patients wereswitched to receive adalimumab 80 mg the first week followed byadalimumab 40 mg eow. During the first 12 weeks of the extension trial,patients remained on blinded therapy.

The Dermatology Life Quality Index (DLQI) was used to evaluate theimprovement in functional limitations of patients with moderate tosevere chronic plaque psoriasis treated with adalimumab. The DLQI is avalidated instrument used to measure disease impact on daily function.DLQI was specified as an endpoint in a 12-week, Phase IIplacebo-controlled trial of two different dose regimens of adalimumab inmoderate to severe plaque psoriasis. The overall study design is shownin FIG. 1. The object of this study was to assess the effects ofadalimumab on the impact of psoriasis in patients' lives.

The DLQI is a validated instrument used to assess dermatologic-relatedfunctional limitations, and was used as the patient related outcomes(PRO) measure. The DLQI consists of ten items and an overall scoringrange of 0-30, where higher scores represent greater quality of lifeimpairment and lower scores represent lower quality of life impairment.The DLQI also includes well-established properties of reliability andvalidity for the DLQI total score in a dermatology setting and measuressix subcategories: symptoms and feelings, daily activities, leisure,work/school, personal relationships, and treatment.

Characteristics of the DLQI include:

-   -   ten items on an overall scoring range of 0-30; higher scores        represent greater quality of life impairment and lower scores        represent lower quality of life impairment;    -   well-established properties of reliability and validity for the        DLQI total score in a dermatology setting (see Badia et        al. (1999) Br J Dermatol 141:698; Finlay et al. (1994) Clin Exp        Dermatol 19:210; and Shikier et al. (2003) Health and Quality of        Life Outcomes 1:53);    -   six subcategories: symptoms and feelings; daily activities;        leisure; work/school; personal relationships; and treatment;    -   all data are observed values. Patients who discontinued before        the time point were not included in this analysis.        Ranges of DLQI scores were evaluated for their correspondence to        categories of disease impact and are described below in Table 1.

TABLE 1 DLQI total score and disease impact on daily life (see Hongbo etal. (2004) Br J Dermatol 151 (suppl. 68)45; Hongbo et al. (2005) InvestDermatol) DLQI Total Score Disease Impact 0-1 None 2-5 Small  6-10Moderate 11-20 Large 21-30 Extremely largeThe results were obtained from 147 patients, who were randomized andtreated as described above. Patient demographics are provided below inTable 2:

TABLE 2 Baseline Demographics and Clinical Characteristics AdalimumabAdalimumab Placebo 40 mg eow 40 mg weekly (n = 52) (n = 45) (n = 50) Age(yrs) 43 46 44 Range (20-70)  (20-71)  (24-86)  Duration of Psoriasis(yrs)   19.1   20.5   18.4 Range (1.0-39.8) (1.3-57.9) (1.7-47.7) % Male65 71 66 % Caucasian 92 89 90 Body Weight (kg) 94 93 99 Range (50-147)(63-159) (42-149) % BSA   27.7   29.2 V24.6 Range (7-75) (6-58) (5-83)PASI Score   16.0   16.7   14.5 Range (5.5-40.4) (5.4-39.0) (2.3-42.4) %with Psoriatic Arthritis 31 33 24 Mean values.

At baseline, 56% of patients reported a very large/extremely largedisease effect as assessed by baseline DLQI scores, as shown below inTable 3:

TABLE 3 Disease impact at baseline by treatment group Disease Impact Ada40 mg eow Ada 40 mg weekly Placebo Moderate 27% 24% 39% Large/ 60% 60%50% Extremely Large

By week 12, 85% of patients with large/extremely large disease impact atbaseline who were randomized to adalimumab had no/small disease effect,compared with 1 (4%) placebo patient. More specifically, 85% of patientsreceiving ada 40 mg eow and 86% patients receiving ada 40 mg weekly hada change from large/extremely large impact at baseline to no/smallimpact at week 12. This level of improvement was maintained for up to 60weeks of treatment with adalimumab as shown in Table 4.

TABLE 4 Percentages of patients with change from large/extremely largeimpact at baseline to no/small impact at weeks 24, 36, and 60 Weeks Ada40 mg eow Ada 40 mg weekly 24 85% 88% 36 83% 91% 60 83% 100%Of placebo patients with large/extremely large impact at baseline, 67%had improved to no/small effect by week 24 after switching to adalimumabat week 12. More specifically, the percentage of patients with a changefrom large/extremely large impact at baseline to no/small impact at week24 was 67%; at week 36 was 79%; and at week 60 was 71%.

In conclusion, rapid reduction in disease impact was seen withadalimumab treatment of moderate to severe plaque psoriasis. Patientsinitially treated with placebo experienced a similar level ofimprovement after 12 weeks of treatment with adalimumab. Resolution ofdisease impact was maintained in most patients through 60 weeks ofadalimumab treatment.

Example 2: Efficacy and Safety of Adalimumab Treatment of Chronic PlaquePsoriasis in Patients Who Meet Some Criteria for BiologicalInterventions in Accordance with British Association of DermatologistsGuidelines

The British Association of Dermatologists (BAD) has published guidelinesfor the treatment of psoriasis with approved biologic interventions suchas infliximab, etanercept, and efalizumab. This subanalysis studymeasured the efficacy of to adalimumab in patients from the above studywho qualified for biologic treatment under these guidelines.

The efficacy and safety of adalimumab in patients eligible for biologictherapy under selected BAD guidelines was evaluated. The selected BADguidelines included a PASI ≧10 and a DLQI >10. The efficacy outcomemeasures were PASI, PGA, and DLQI. FIG. 1 shows the study design.

The following analytic methods were employed in this subanalysis:modified intention to treat analyses were preformed on all randomizedpatients receiving at least one dose of adalimumab; missing data wereimputed using non-responder imputation (NRI) for PASI and PAG andobserved data for DLQI; and a post-hoc analysis was conducted to examinekey efficacy and safety outcomes for patients who were eligible fortreatment with a biological agent as specified in the current BADguidelines (PASI ≧10 and a DLQI >10).

For the patients who met the selected BAD criteria, the baselinedemographics and disease severity characteristics were similar acrosstreatment groups. These characteristics were consistent with those ofthe overall patient population. Table 5 shows the overall baselinedemographics and clinical characteristics of the patients enrolled inthe overall study (not just specific to BAD).

TABLE 5 Adalimumab Adalimumab Placebo 40 mg eow 40 mg weekly (N = 52) (N= 45) (N = 50) Age, years (range)  43 (20-70)  46 (20-71)  44 (24-86)Duration of Ps, years 19 (1-40) 21 (1-58) 18 (2-48) (range) % Male 65 7166 % Caucasian 92 89 90 Body Weight, kg (range) 94 (50-147) 93 (63-159)99 (42-149) % BSA (range) 28 (7-75) 29 (6-58) 25 (5-83) PASI Score(range) 16 (6-40) 17 (5-39) 15 (2-42) DLQI Score 12 13 14Table 6 shows the overall baseline demographics and clinicalcharacteristics for patients included in this subanalysis (those who metthe above described selected BAD guidelines).

TABLE 6 Adalimumab Adalimumab Placebo 40 mg eow 40 mg weekly (N = 18) (N= 26) (N = 23) Age, years (range) 44 (20-70) 45 (20-71) 42 (24-86)Duration of Ps, years 19 (5-40)  19 (1-58)  19 (2-48)  (range) % Male 6165 61 % Caucasian 89 85 91 Body Weight, kg (range)  89 (57-146)  92(70-159) 104 (42-149) % BSA (range) 37 (10-75) 31 (8-56)  35 (10-83)PASI Score (range) 20 (11-34) 19 (11-39) 19 (11-42) DLQI Score 18 18 18

TABLE 7 Overall PASI 75 Response Rates Up To Week 60 Treatment % ofPatients Week 12 Placebo  4 n = 147 Placebo/Adalimumab 40 mg eow —Adalimumab 40 mg eow  53* Adalimumab 40 mg weekly  80* Week 24 Placebo —n = 142 Placebo/Adalimumab 40 mg eow 55 Adalimumab 40 mg eow 64Adalimumab 40 mg weekly 72 Week 36 Placebo — n = 142 Placebo/Adalimumab40 mg eow 62 Adalimumab 40 mg eow 64 Adalimumab 40 mg weekly 68 Week 60Placebo — n = 142 Placebo/Adalimumab 40 mg eow 45 Adalimumab 40 mg eow58 Adalimumab 40 mg weekly 64 At Week 12, placebo patients received80-mg loading dose, then 40 mg eow. Modified ITT, NRI. *p < 0.001 vs.placebo/adalimumab 40 eow group. Patients with <PASI 50 response on orafter Week 24 were eligible to receive OL weekly adalimumab rescuetherapy. Patients receiving rescue therapy were considerednon-responders in this analysis.

As can be seen in Table 7, a substantial portion of all patientsachieved and sustained a PASI 75 response up to Week 60 of adalimumabtreatment. Also seen in Table 6, placebo patients who started adalimumabat Week 12 achieved rapid improvements in their PASI scores, asindicated by PASI 75 response rates at Week 24.

TABLE 8 Overall DLQI Scores Up To Week 60 Treatment % of Patients Week12 Placebo 11  n = 140 Placebo/Adalimumab 40 mg — eow Adalimumab 40 mgeow 4 Adalimumab 40 mg weekly 3 Week 24 Placebo — n = 131Placebo/Adalimumab 40 mg 3 eow Adalimumab 40 mg eow 5 Adalimumab 40 mgweekly 3 Week 36 Placebo — n = 118 Placebo/Adalimumab 40 mg 2 eowAdalimumab 40 mg eow 3 Adalimumab 40 mg weekly 2 Week 60 Placebo — n =106 Placebo/Adalimumab 40 mg 2 eow Adalimumab 40 mg eow 4 Adalimumab 40mg weekly 1 At Week 12, placebo patients received 80-mg loading dose,then 40 mg eow. Modified ITT, observed. Patients with < PASI 50 responseon or after Week 24 were eligible to receive OL weekly adalimumab rescuetherapy. Patients receiving rescue therapy were considerednon-responders in this analysis.Table 8 shows the overall DLQI scores up to Week 60 for patientsincluded in the subanalysis study. As can be seen in this figure, allpatients demonstrated a significant improvement in DLQI scores up toWeek 60 of adalimumab treatment. Also, placebo patients who startedadalimumab at Week 12 achieved rapid improvements in DLQI scores.

Overall, substantial percentages of patients who met the selected BADcriteria to achieved PASI 75 responses, comparable to PASI 75 responserates in the overall patient population (see Table 9). PASI improvementswere largely sustained out to Week 60 (Table 9).

TABLE 9 PASI 75 Response Rates Up To Week 60 in Patients With BaselinePASI ≧10 and DLQI >10 n Treatment % of Patients Week 12 18 Placebo  0 26Placebo/Adalimumab 40 mg — eow 23 Adalimumab 40 mg eow 69 — Adalimumab40 mg weekly 74 Week 24 — Placebo — 15 Placebo/Adalimumab 40 mg 50 eow26 Adalimumab 40 mg eow 77 23 Adalimumab 40 mg weekly 78 Week 36 —Placebo — 15 Placebo/Adalimumab 40 mg 50 eow 26 Adalimumab 40 mg eow 7323 Adalimumab 40 mg weekly 74 Week 60 — Placebo — 15 Placebo/Adalimumab40 mg 44 eow 26 Adalimumab 40 mg eow 65 23 Adalimumab 40 mg weekly 65 AtWeek 12, placebo patients received 80-mg loading dose, then 40 mg eow.Modified ITT, NRI. Patients with < PASI 50 response on or after Week 24were eligible to receive OL weekly adalimumab rescue therapy. Patientsreceiving rescue therapy were considered non-responders in thisanalysis.

Also, in the subset of patients who met the selected BAD criteria forbiologic treatment, patients achieved and largely sustained clinicalimprovements as demonstrated by PASI 90 responses to Week 60 (Table 10).As can be seen in Table 11, there were significant percentages ofpatients who achieved a PGA score of “Clear” or “Almost Clear” andsustained these responses until Week 60.

TABLE 10 PASI 90 Response Rates Up To Week 60 in Patients With BaselinePASI ≧10 and DLQI >10 n Treatment % of Patients Week 12 18 Placebo  0 26Placebo/Adalimumab 40 mg — eow 23 Adalimumab 40 mg eow 39 — Adalimumab40 mg weekly 61 Week 24 — Placebo — 15 Placebo/Adalimumab 40 mg 28 eow26 Adalimumab 40 mg eow 54 23 Adalimumab 40 mg weekly 70 Week 36 —Placebo — 15 Placebo/Adalimumab 40 mg 50 eow 26 Adalimumab 40 mg eow 5823 Adalimumab 40 mg weekly 65 Week 60 — Placebo — 15 Placebo/Adalimumab40 mg 39 eow 26 Adalimumab 40 mg eow 42 23 Adalimumab 40 mg weekly 48 AtWeek 12, placebo patients received 80-mg loading dose, then 40 mg eow.Modified ITT, NRI. Patients with < PASI 50 response on or after Week 24were eligible to receive OL weekly adalimumab rescue therapy. Patientsreceiving rescue therapy were considered non-responders in thisanalysis.

TABLE 11 PGA “Clear” or “Almost Clear” Up To Week 60 in Patients WithBaseline PASI ≧10 and DLQI >10 n Treatment % of Patients Week 12 18Placebo  0 26 Placebo/Adalimumab 40 mg — eow 23 Adalimumab 40 mg eow 62— Adalimumab 40 mg weekly 70 Week 24 — Placebo — 15 Placebo/Adalimumab40 mg 33 eow 26 Adalimumab 40 mg eow 69 23 Adalimumab 40 mg weekly 74Week 36 — Placebo — 15 Placebo/Adalimumab 40 mg 44 eow 26 Adalimumab 40mg eow 65 23 Adalimumab 40 mg weekly 65 Week 60 — Placebo — 15Placebo/Adalimumab 40 mg 39 eow 26 Adalimumab 40 mg eow 54 23 Adalimumab40 mg weekly 52 At Week 12, placebo patients received 80-mg loadingdose, then 40 mg eow. Modified ITT, NRI. Patients with < PASI 50response on or after Week 24 were eligible to receive OL weeklyadalimumab rescue therapy. Patients receiving rescue therapy wereconsidered non-responders in this analysis..

Adalimumab-treated patients showed rapid and sustained improvement intheir DLQI scores (Table 12), with mean scores of 3.0 and 0.7 at Week 60in the adalimumab every other week and adalimumab weekly groupsrespectively.

TABLE 12 Change in DLQI Scores Up To Week 60 in Patients With BaselinePASI ≧10 and DLQI >10 Mean change n Treatment from baseline Week 12 15Placebo  −2 26 Placebo/Adalimumab 40 mg — eow 22 Adalimumab 40 mg eow−15 — Adalimumab 40 mg weekly −16 Week 24 — Placebo — 15Placebo/Adalimumab 40 mg −12 eow 25 Adalimumab 40 mg eow −14 20Adalimumab 40 mg weekly −17 Week 36 — Placebo — 13 Placebo/Adalimumab 40mg −14 eow 22 Adalimumab 40 mg eow −15 18 Adalimumab 40 mg weekly −18Week 60 — Placebo — 12 Placebo/Adalimumab 40 mg −12 eow 22 Adalimumab 40mg eow −15 15 Adalimumab 40 mg weekly −17 At Week 12, placebo patientsreceived 80-mg loading dose, then 40 mg eow. Modified ITT, observed.Patients with < PASI 50 response on or after Week 24 were eligible toreceive OL weekly adalimumab rescue therapy. Patients receiving rescuetherapy were considered non-responders in this analysis.

As can be seen in Table 13, withdrawal rates due to adverse events inthis post-hoc analysis were comparable for patients treated withadalimumab every other week and adalimumab weekly.

TABLE 13 Weeks 12-60 Weeks 0-12 Placebo/ Adalimumab AdalimumabAdalimumab 40 mg eow + Adalimumab Placebo 40 mg eow 40 mg weeklyAdalimumab 40 mg eow 40 mg weekly Event, n (%) (N = 18) (N = 26) (N =23) (N = 41) (N = 23) Any AE 13 (72) 16 (62) 19 (83) 23 (56) 11 (48)Serious AEs 0 (0) 0 (0) 2 (9) 1 (2) 0 (0) Any Infectious 0 (0) 0 (0) 0(0) 0 (0) 0 (0) Serious AEs AEs leading to 1 (6) 0 (0) 1 (4) 2 (5) 0 (0)withdrawal

Overall, patients with moderate to sever plaque psoriasis achievedsustained efficacy up to Week 60 of treatment with adalimumab.Adalimumab treatment significantly reduced the signs and symptoms andimproved the quality of life in patients with psoriasis who meet some ofthe necessary criteria of the BAD guidelines for biologic treatment. Theadverse events observed in this study were similar to those previouslyreported in adalimumab rheumatoid arthritis and psoriatic arthritistrials.

Example 3: Recent History of Systemic or Biologic Therapy Does NotAdversely Affect Adalimumab Efficacy and Safety in Patients withModerate to Severe Chronic Plaque Psoriasis

Psoriasis is a chronic, inflammatory proliferative disease of the skinthat affects 1-3% of the general population (Greaves and Weinstein(1995) N Engl J Med 332: 581). Treatment of moderate to severe psoriasiswith systemic therapy such as methotrexate or cyclosporine or biologictherapy such as efalizumab can be limited by lack of efficacy orprecluded by side effects. Ultraviolet light therapy is ofteninconvenient.

Previous studies demonstrated adalimumab is effective in treatingmoderate to severe plaque psoriasis (Ps), with an acceptable safetyprofile. Some study patients had a recent (within past 12 months)history of exposure systemic or biologic (except TNF antagonists)therapy, but could enroll if systemic therapy stopped at least 4 wksprior to study (at least 12 wks for biologics). The impact of priortreatment with these agents on the safety and efficacy of patientsreceiving adalimumab is a practical concern to physicians and patientsand was investigated in this subanalysis. Thus, the following studydescribes an analysis of the efficacy and safety of adalimumab treatmentin psoriasis patients with or without recent exposure to systemic orbiologic agents.

The objective of the study was to investigate the impact of priortreatment with systemic non-biologic or biologic therapies on the safetyand efficacy of adalimumab in patients with psoriasis

The efficacy and safety of adalimumab was evaluated in a 12-week,double-blind, placebo-controlled trial, followed by a 48-week extension,conducted at 18 sites two different countries. Inclusion criteria forthe study included the following parameters: 18 years of age; moderateto severe chronic plaque psoriasis 1 year; and affected BSA 5%.Exclusion criteria for the study included prior TNF-antagonist therapyand discontinuation of other systemic psoriasis therapies. Impact ofprior biologics, other than TNF antagonists, on the safety and efficacyof adalimumab for psoriasis was measured in this subanalysisn study.Efficacy outcome measures included PASI and PGA. Analytical methodsincluded the following:

-   -   Modified intent-to-treat analyses were performed on all        randomized patients receiving at least one dose of adalimumab    -   Missing data were imputed using non-responder imputation    -   Subanalyses were conducted on the outcomes of patients who were        and were not exposed to systemic therapy within 12 months of        study entry        A diagram of the study design is shown in FIG. 1.

Out of 148 patients enrolled in a double-blind, placebo (pbo)-controlledstudy, 147 patients received at least one dose of study medication in 1of 3 randomized treatment arms: 1) pbo (n=52); 2) adalimumab 80 mgsubcutaneous (sc) at Wk 0, then 40 mg sc every other wk (eow) startingat Wk 1 (n=45); and 3) adalimumab 80 mg sc at Wks 0 and 1, then 40 mg scwkly (qw) starting at Wk 2 (n=50). Placebo patients were eligible atWeek 12 to receive adalimumab 40 mg eow (placebo/adalimumab eow).

Baseline data were similar among randomization groups. Baselinedemographics, disease severity characteristics, and recent history ofsystemic therapies were similar across the treatment groups. Table 2shows the baseline demographics and clinical characteristics.

Systemic non-biologic therapies taken by more than 2% of patientsincluded methotrexate (16%), oral tazarotene (11%), cyclosporine (9%),and acitretin (4%). The only systemic biologic therapy taken by morethan 2% of patients was efalizumab (15%) (prior use of TNF-antagonisttherapy was an exclusion criterion for study entry). Table 14 showsclinical characteristics of the patients involved in the study,including recent past history of systemic therapy.

TABLE 14 Clinical Characteristics: Recent Past History of SystemicTherapy* Adalimumab Adalimumab Placebo 40 mg eow 40 mg weekly (N = 52)(N = 45) (N = 50) No Recent History of 28 (54) 23 (51) 25 (50) SystemicTherapy, n (%) Recent History of Systemic 19 (37) 19 (42) 22 (44)Non-biologic Therapy, n (%) Recent History of Systemic  8 (15)  8 (18) 9 (18) Biologic Therapy, n (%) *Within 12 months of study entry.Percentages in each column do not sum to 100 because some patients hadrecent history of systemic non-biologic and biologic therapy. Thenumbers of patients exposed to multiple types of systemic therapy weretoo small to permit meaningful analysis of their outcomes.

The results show that substantial percentages of all patients achievedand sustained PASI 75 responses up to Week 60 of adalimumab treatment.In addition, placebo patients who started adalimumab at Week 12 attainedclinically significant improvement in their PASI 75 response rates byWeek 24. These results are described to in Table 6.

Patients with and without a recent history of systemic non-biologic orbiologic therapy had similar percentages of PASI 75 responses at Week24, which were largely sustained out to Week 60. Tables 15 and 16 showsPASI 75 response rates in patients stratified by recent history ofsystemic therapy at week 24 (Table 15) and week 60 (Table 16).

TABLE 15 PASI 75 Response Rates at Week 24 in Patients Stratified byRecent History of Systemic Therapy n Treatment % Patients Prior Systemic17 Placebo/Adalimumab 40 mg 47 Use eow 19 Adalimumab 40 mg eow 68 22Adalimumab 40 mg weekly 73 Prior 8 Placebo/Adalimumab 40 mg 63Biological Use eow 8 Adalimumab 40 mg eow 50 9 Adalimumab 40 mg weekly67 No Prior Use 25 Placebo/Adalimumab 40 mg 56 eow 23 Adalimumab 40 mgeow 65 25 Adalimumab 40 mg weekly 76 Modified ITT, NRI.

TABLE 16 PASI 75 Response Rates at Week 60 in Patients Stratified byRecent History of Systemic Therapy n Treatment % Patients Prior Systemic17 Placebo/Adalimumab 40 mg 41 Use eow 19 Adalimumab 40 mg eow 68 22Adalimumab 40 mg weekly 64 Prior 8 Placebo/Adalimumab 40 mg 63Biological Use eow 8 Adalimumab 40 mg eow 63 9 Adalimumab 40 mg weekly78 No Prior Use 25 Placebo/Adalimumab 40 mg 40 eow 23 Adalimumab 40 mgeow 48 25 Adalimumab 40 mg weekly 64 Modified ITT, NRI.

Patients with and without a recent history of systemic non-biologic orbiologic therapy who received adalimumab 40 mg eow dosing achieved andlargely sustained clinical improvement to Week 60, as measured by avariety of secondary efficacy variables. Table 17 shows secondaryefficacy outcomes after 60 weeks of adalimumab 40 mg eow.

TABLE 17 PASI PASI PASI % PGA “Clear”/ 50 (%) 90 (%) 100 (%) “AlmostClear” No Prior Use 65 30 17 44 Prior Systemic 68 37 11 47 Use PriorBiologic Use 63 38 13 38

Table 18 show PASI responses up to week 60. Overall, percent of PASI 75responders in the (placebo/adalimumab eow)/adalimumab eow/adalimumabweekly arms were 55/64/72 at Wk 24 and 45/58/64 at Wk 60, respectively.For patients with prior biologic therapy (n=25), the rates were 63/50/67at Week 24 and 63/63/78 at Week 60. For patients in neither of thesegroups (n=73), the rates were 56/65/76 at Week 24 and 40/48/64 at Week60.

TABLE 18 Percentages of PASI 75 responders for each subgroup at Wks 24and 60 Wk 60 Wk 24 Adalimumab eow Pbo/Adalimumab (formerly Pbo)/ eow/Adalimumab eow/ Adalimumab qw Adalimumab qw Systemic, n = 58 (%)47/68/73 41/68/64 Biologic, n = 25 (%) 63/50/67 63/63/78 Other, n = 73(%) 56/65/76 40/48/64

Withdrawal rates due to adverse events were similarly low for patientstreated with adalimumab eow and adalimumab weekly. All patients treatedwith adalimumab in the double-blind portion of the trial continued intothe open-label extension. The percentage of patients who withdrew due toadverse events between Weeks 12 and 60 ranged from 3.3% to 10.0%

Serious adverse events (SAEs) were detected in 7 prior-systemicpatients, 4 prior-biologic patients, and 5 patients without recent priorsystemic or biologic therapy during the 60-week trial. Most SAEs did notappear to be related to adalimumab use. to Table 19 shows adverse eventsby treatment period, while Tables 20 and 21 shows adverse events bysubgroup (Table 20: weeks 0-12; Table 21: Weeks 12-60).

TABLE 19 Adverse Events by Treatment Period Weeks 12-60 Weeks 0-12Placebo/ Adalimumab Adalimumab Adalimumab 40 mg eow + Placebo 40 mg eow40 mg weekly Adalimumab 40 mg eow Adalimumab Event, n (%) (N = 52) (N =45) (N = 50) (N = 92) 40 mg weekly Any AE 35 (67) 28 (62) 39 (78) 72(78) 39 (78)  Serious AEs 0 (0) 1 (2) 4 (8) 2 (2) 7 (14) AEs leading to1 (1) 2 (4) 3 (6) 3 (3) 5 (10) withdrawal

TABLE 20 Adverse Events by Subgroup: Weeks 0-12 - Results for PatientsStratified by Recent Past History Placebo Adalimumab 40 mg eowAdalimumab 40 mg weekly No Prior Prior No Prior Prior No Prior PriorSystemic Biologic Prior Systemic Biologic Prior Systemic Use Use Use UseUse Use Use Use Prior Biologic (n = 28) (n = 19) (n = 8) (n = 23) (n =19) (n = 8) (n = 25) (n = 22) Use (n = 9) Any AE, n (%) 18 (64) 15 (79) 5 (63) 16 (70) 11 (58)  2 (25) 20 (80) 17 (77) 6 (67) Serious AE, n 0(0) 0 (0) 0 (0) 0 (0) 1 (5) 0 (0) 1 (4) 2 (9) 2 (22) (%) AE's→ 0 (0) 1(5) 0 (0) 1 (4) 1 (5) 0 (0) 1 (4) 1 (5) 2 (22) Withdrawal, n (%)

TABLE 21 Adverse Events by Subgroup: Weeks 12-60 - Results for PatientsStratified by Recent Past History Placebo/Adalimumab 40 mg eow +Adalimumab 40 mg eow Prior Adalimumab 40 mg weekly No Prior SystemicPrior Systemic Prior Biologic Use Use Prior Biologic No Prior Use UseUse (n = 47) (n = 35) Use (n = 16) (n = 24) (n = 21) (n = 7) Any AE (%)37 (79) 28 (80) 12 (75) 19 (79) 17 (81)   6 (86) Serious AE 0 (0) 2 (6) 2 (13)  4 (17) 2 (10) 0 (0) (%) AE's→ 1 (2) 2 (6) 1 (6) 2 (8) 3 (14) 0(0) Withdrawal (%)The most frequent adverse events, between weeks 12 and 60 are describedin Table 22.

In conclusion, patients with moderate to severe psoriasis achievedsustained efficacy up to week 60 of treatment with adalimumab. Priorbiologic or non-biologic therapy did not appear to adversely affectadalimumab efficacy or safety in patients with moderate to severepsoriasis. Finally, the types and rates of adverse events in this studyto were similar to those previously reported in adalimumab RA and PsAtrials. In sum, this post-hoc analysis suggests that recent treatmentwith systemic or biologic therapy does not adversely affect adalimumabefficacy or safety in moderate to severe psoriasis patients.

TABLE 22 Most frequent adverse events, between weeks 12 and 60Adalimumab Placebo/Adalimumab 40 mg 40 mg eow + Adalimumab 40 mg eowweekly Event (N = 92) (N = 50) Nasopharyngitis 13 (14.1) 6 (12.0) URI,NOS 9 (9.8) 7 (14.0) URI, viral NOS 4 (4.3) 3 (6.0) Muscle strain 1(1.1) 4 (8.0) Blood CPK 5 (5.4) 2 (4.0) increased Blood TG increased 7(7.6) 2 (4.0) Back pain 4 (4.3) 4 (8.0) Skin papilloma 3 (3.3) 5 (10.0)Headache 3 (3.3) 6 (12.0) Urticari 0 (0.0) 3 (6.0) URI = upperrespiratory infection; NOS = not otherwise specified; CPK = Creatinephosphokinase; TG = Triglycerides.

Example 4: Improvements in DLQI in Moderate to Severe Plaque PsoriasisPatients Treated with Adalimumab

The following example provides additional details regarding DermatologyLife Quality Index (DLQI) changes in a Phase II clinical study, asdescribed in Examples 1, 3, 5, 6, and 8. The study showed that changesin functional ability as measured by DLQI were consistent with clinicalresponse in moderate to severe plaque psoriasis patients treated withadalimumab. The following example also describes the Minimum ClinicallyImportant Difference (MCID) in DLQI in moderate to severe plaquepsoriasis to patients treated with adalimumab.

Because psoriasis exerts substantial deleterious effects on physicalfunction and quality of life (HRQOL) (see de Arruda et al. (2001) Br JDermatol 144 (Suppl 58):33; Finlay (1998) Seminars Cutan Med Surgery17:291; Rapp et al. (2001) Br J Dermatol 145:610; and Wahl et al. (2000)J Am Acad Dermatol 43:803), patient-reported outcomes (PROs) helpevaluate the beneficial effects of treatment, in addition to clinicalendpoints.

The minimum clinically important difference (MCID) is defined as “thesmallest difference in score that patients perceive as beneficial” (seeJuniper et al. (1994) J Clin Epidemiol 47:81). While clinical trials ofbiologics in the treatment of psoriasis have included PROs—particularlythe Dermatology Life Quality Index (DLQI) (see Feldman et al. (2004) BrJ Dermatol 150:317; Finlay et al. (2003) Dermatology 206:307; Gordon etal. (2003) JAMA 290:3073; Gottlieb et al. (2003) Arch Dermatol 139:1627;Leonardi et al. (2003) N Engl J Med 349:2014; and Menter et al. (2004) JDrugs Dermatol 3:27)—the clinical relevance and MCID for this instrumenthave not been established in moderate to severe plaque psoriasis.

The following describes a study which examined the DLQI as a secondaryefficacy endpoint in a 12-week study (placebo-controlled trial) of twodifferent dose regimens of adalimumab in moderate to severe plaquepsoriasis. Thus, one of the objectives of the study was to estimate thesensitivity of DLQI to clinical changes associated with moderate tosevere plaque psoriasis. An additional objective was to determine theMCID for use in future studies and treatments.

Patients were randomized into one of the following treatment groups: 80mg adalimumab at baseline (week 0) and 40 mg at week 1 followed by 40 mgevery other week (eow) starting at week 3 (referred to as ada 40 mgeow); 80 mg adalimumab at baseline (week 0) and 80 mg at week 1 followedby 40 mg weekly starting at week 2 (referred to as ada 40 mg weekly); orplacebo administered weekly beginning at baseline (referred to asplacebo). Inclusion criteria included a diagnosis of moderate to severechronic plaque psoriasis >1 year prior to entry, a psoriasis-affectedbody surface area (BSA) >5%, and no previous TNF-antagonist therapy.

The two primary clinical outcome measures used in this study were thepsoriasis area and severity index (PASI) and the physician's globalassessment (PGA). PASI improvement of greater than or equal to 75% (usedas an endpoint in psoriasis clinical trials) at week 12 was the primaryefficacy outcome measure for this study. PASI is a composite indexindicating severity for three main signs of psoriatic plaques (erythema,scaling, and thickness), weighted by the amount of coverage of theseplaques in four main body areas, i.e., head, trunk, upper extremities,and lower extremities. PASI to scores, which range from 0-72, withhigher scores indicating greater severity, were assessed at screening,baseline, week 1, week 2, week 4, week 8, week 12/early termination, andfollow-up.

PROs were assessed using the DLQI. The DLQI is a validated instrumentused to assess dermatologic-related functional limitations.Characteristics of the DLQI include: ten items on an overall scoringrange of 0-30; higher scores represent greater quality of lifeimpairment and lower scores represent lower quality of life impairment;well-established properties of reliability and validity for the DLQItotal score in a dermatology setting (see Badia et al. (1999) Br JDermatol 141:698; Finlay et al. (1994) Clin Exp Dermatol 19:210; andShikier et al. (2003) Health and Quality of Life Outcomes 1:53); and sixsubcategories: symptoms and feelings; daily activities; leisure;

work/school; personal relationships; and treatment.

The Physician's Global Assessment (PGA), which was used as a clinicalendpoint in the trial, was used to determine the MCID for DLQI. The PGAis a seven point scale used to measure disease severity from aphysician's evaluation. Scoring under the PGA ranges from 1 (Clear) to 7(Severe). Categories for the 7-point scale include the following:

-   -   Severe: very marked plaque elevation, scaling and/or erythema;    -   Moderate to severe: marked plaque elevation, scaling and/or        erythema;    -   Moderate: moderate plaque elevation, scaling and/or erythema;    -   Mild to moderate: intermediate between moderate and mild;    -   Mild: slight plaque elevation, scaling and/or erythema;    -   Almost clear: intermediate between mild and clear; and    -   Clear: no signs of psoriasis (post-inflammatory hypopigmentation        or hyperpigmentation could be present).        Scoring regions were from 1 (clear) to 7 (severe). PGA was        assessed at screening; baseline; week 1; week 2; week 4; week 8;        and week 12 early termination; and follow up. The same        investigator performed the assessment for each patient        throughout the study. Statistical methods were performed        according to the following summary. Analyses were performed on        blinded data, combining results from all three groups. Changes        in the PGA from baseline to week 12 were correlated with changes        in DLQI total score.

Mean changes in DLQI total score were calculated and compared for twosets of patients: those whose PGA scores improved by 1 or 2 points(“minimal responders”) and those whose PGA scores stayed the same ofdeclined or declines by 1 point “non-responders”). It should be notedthat there is no universally accepted method to calculate MCID. Onemethod to estimate the MCID is to calculate the difference between themean DLQI changes for patients classified as “minimal responders” andthe to changes for patients classified as “non-responders.” Othermethods to calculate MCID are based on mean DLQI change corresponding toPASI improvement 25%-49%. MCID for DLQI was also calculated based onmean DLQI change corresponding to PASI improvement 50%-74% and based onthree distributional methods: standard error of the mean (SEM) change inDLQI; upper limit of the 95% confidence interval of the SEM; and half ofthe standard deviation (SD) of the DLQI mean change. MCID was applied todemonstrated changes in DLQI total score from baseline to week 12 in thethree randomized groups of this trial. All data were observed values,and patients who discontinued before the time point were not included inthe analysis.

Changes in the clinical measures from baseline to week 12 were alsocorrelated with changes in DLQI total score. Mean changes in DLQI totalscore were calculated and compared by level of PASI response (PASIImprovement <25%; PASI Improvement 25-49%; PASI Improvement 50-74%, andPASI Improvement >75%). MCID for DLQI was determined based on mean DLQIchange corresponding to PASI Improvement 25-49% (the study did notafford independent verification of the correspondence of this level ofimprovement with a level patients would indicate represents noticeablebut minimum improvement. Nonetheless, these patients were characterizedas “near responders,” as patients with psoriasis who achieve PASIImprovement of 50-75% are sometimes termed “partial-responders”). MCIDdetermination was also based on three standard distributionalmethods: 1) standard error of the mean (SEM) change in DLQI; 2) upperlimit of the 95% confidence interval of the SEM; and 3) half of thestandard deviation (SD) of the DLQI mean change. MCID was applied todemonstrated changes in DLQI total score from baseline to week 12 in thethree randomized groups of this Phase II trial.

147 patients from 18 different sites enrolled in the study and receivedat least one dose of study medication. Demographic characteristics areprovided below in Table 23:

TABLE 23 Demographic Characteristics Characteristic (N = 147) Age Mean(SD) 44.2 (12.7)   Gender Female n (%) 48 (32.7%) Male n (%) 99 (67.3%)Race White n (%) 133 (90.5%)  Black n (%) 4 (2.7%) Asian n (%) 5 (3.4%)Other n (%) 5 (3.4%)

Data were available for 140 of the 147 patients at the end of the trial.Mean values for DLQI and PGA at baseline and week 12 are shown below inTable 24:

TABLE 24 Mean (SD) of DLQI and PGA at Baseline and Week 12 Baseline Week12 Change² (N = 147) (N = 140) (N = 140) DLQI Total Score 12.7 (7.2) 5.3(6.5) −7.5 (7.8) Physician's Global  5.5 (0.8) 3.4 (1.7) −2.1 (1.9)Assessment¹ (PGA) Psoriasis and Severity 16.7 (7.3) 6.8 (7.8) −8.9 (8.4)Index (PASI) ¹Scored such that 1 = “Clear” to 7 = “Severe” ²Calculatedonly for patients with both baseline and week-12 scores (Numbers inparentheses are standard deviations (SD)).

Correlation PASI

The correlation coefficient for DLQI total score and PASI was 0.69(p<0.001), and for DLQI total score and PGA was 0.71 (p<0.001) (seeTable 25). In addition, the results show that DLQI was highly correlatedwith clinical endpoints (see Table 26).

TABLE 25 Correlations* Between Changes in DLQI and Psoriasis Area andSeverity Index (PASI) and Physician's Global Assessment (PGA) PASI PGADLQI Total Score 0.69 0.71 PASI 1.00 0.75 *All correlations aresignificant at p < 0.001.

TABLE 26 Correlations between DLQI and Clinical Endpoints Baseline Week12 PASI PGA PASI PGA DLQI 0.31 0.29 0.67 0.65 PASI 1.00 0.5 1.00 0.83 p< 0.001 for all correlations. PASI = Psoriasis Area and Severity Index.PGA = Physician's Global Assessment.

Corresponding mean (SD) DLQI change scores improved with increases inPASI response (p<0.001), as shown in Table 27.

TABLE 27 Mean (SD) DLQI Change Score Corresponding to Levels of PASIImprovement PASI Improvement <25% 25%-49% 50%-74% ≧75% Overall (N = 31)(N = 22) (N = 21) (N = 66) F-Value DLQI Total −0.16 (5.41) −4.05 (4.95)−6.95 (5.71) −12.17 (6.78) 30.4* Score Negative change scores indicateimprovement; p-values are: *<0.001. Post-hoc tests indicate that thePASI >75% differed significantly from each of the three other groups. Inaddition, the PASI <25% group differed significantly from the PASI50-74% group. Numbers in parentheses are standard deviations (SD).

It is believed that these data support an MCID in the range of 2.3-4.0,which is consistent with estimates derived from a prior analysis of datafrom two psoriasis clinical trials. The mean change in DLQI total scorefrom baseline in both adalimumab treatment arms was much greater than anMCID range of 2.3-4.0. The placebo group did not achieve the MCID, asshown in Table 28.

TABLE 28 Mean Change in DLQI at Week 12 Adalimumab Adalimumab Placebo 40mg eow 40 mg weekly Mean change −1.3 −10.8* −11.5* *p < 0.001 vs.placebo MCID 2.3-4.0Table 29 below shows the DLQI improvement corresponding to a PASIimprovement of 25-49%, as well as the three “distributional” estimatesof the MCID.

TABLE 29 Estimates of MCID for the DLQI Change in Scale/Subscale MCID 1:PASI Improvement MCID 2: MCID 3: MCID 4: 25%-49% SEM 1.96 SEM 0.5 SDDLQI Total Score −4.05 (4.95) 2.33 4.57 3.59 Numbers in parentheses arestandard deviations (SD). MCID = minimum clinically importantdifference; SEM = standard error of measurement.PGA correlation

Mean improvements in DLQI between “minimal responders” and“non-responders” based on PGA was significantly different (p<0.0001), asshown in Table 30.

TABLE 30 Mean (SD) DLQI Change Score by PGA Response PGA Minimal PGADifference in Mean Responder Non-Responder DLQI Total Score* DLQI −5.7(5.7) 0.0 (4.7) 5.7 Total Score *p < 0.0001 Note: Negative numbersindicate improvement, positive numbers indicate worsening indermatologic-related functional limitations as measured by DLQI.

Based on the above MCID calculations with PASI (2.3-4) and these MCIDcalculations with PGA (5.7) in the same study population, the MCID forDLQI was estimated to range between 2.3 and 5.7, with the mostconservative estimate of MCID derived from analysis of the mean changein DLQI for PGA “minimal responders.” Table 31 shows DLQI improvement at12 weeks in each of the three arms of the study.

TABLE 31 DLQI improvement at 12 weeks in each of the three arms of thestudy Treatment Mean Change Placebo −1.3 Adalimumab −10.8 40 mg eowAdalimumab −11.5* 40 mg weekly *p < 0.001 vs. Placebo

In conclusion, through a variety of methods, the MCID for the DLQI wasestimated to range between 2.3 and 5.7. Given that adalimumab-treatedpatients demonstrated mean change in DLQI of >10 points, which is wellabove the most conservative estimate of MCID for DLQI, treatment withadalimumab is associated with clinically important improvements indermatologic-related functional limitations.

Example 5: Enhanced Adalimumab Efficacy Following Dosage Escalation inPsoriasis Patients With Subtherapeutic Response to Every-Other-WeekAdalimumab

Adalimumab is a fully human, monoclonal IgG_(i) antibody against TNF. A60- week, Phase II study demonstrated that adalimumab is effective inmoderate to severe plaque psoriasis patients, with an acceptable safetyprofile (see FIG. 1 for study design). Patients with a subtherapeutic(<PASI 50) response to adalimumab at Week 24 could increase theirdosages from every other week (eow) to every week (qw). The objective ofthis study was to assess efficacy and safety of adalimumab weekly dosingin those psoriasis patients who had a subtherapeutic response toevery-other-week adalimumab dosage

Thus, the present subanalysis evaluated adalimumab efficacy and safetyin those patients who increased their dosages.

The efficacy and safety of adalimumab was evaluated in a 48-weekextension trial conducted at 18 sites in the US and Canada. Prior tothis open label study, patients were enrolled in a 12-week,double-blind, placebo-controlled trial. Inclusion criteria includedpatients being 18 years of age; having moderate to severe chronic plaquepsoriasis 1 year; and affected BSA 5%. Exclusion criteria included priorTNF-antagonist therapy and discontinuation of other systemic psoriasistherapies. Efficacy outcome measures which were used included PASI, PGA,DLQI. The study design is shown in FIG. 1. Baseline demographics andclinical characteristics are described in Table 2 above. In addition,the percentage of patients with PsA was 31% placebo, 33% adalimumab 40mg eow, and 24% adalimumab 40 mg weekly.

Randomized treatment arms included: 1) placebo (n=52); 2) adalimumab 80mg subcutaneously (sc) at Week 0, then 40 mg sc eow starting at Week 1(n=45); and 3) adalimumab 80 mg sc at Weeks 0 and 1, then 40 mg sc qwstarting at Week 2 (n=50). At Week 12, placebo patients were switched toadalimumab 40 mg eow (placebo/eow). At Week 24 and thereafter,adalimumab eow patients with <PASI 50 improvement from baseline startedadalimumab 40 mg qw. Skin and safety outcomes were assessed up to Week60.

Of 148 patients enrolled in the double-blind, placebo-controlled study,147 received at least one dose of study medication. At Week 24, PASI 50responses were 77/73/80 and PASI 75 responses were 55/64/72 for the(placebo/eow)/eow/weekly arms, respectively.

On or after Week 24, 18 of the 47 patients in the placebo/adalimumab eowgroup and 12 of the 45 patients in the adalimumab eow group achieved aPASI <50 response, which qualified them for dosage escalation toadalimumab weekly (Table 32)

TABLE 32 Number of Patients Who Qualified for Dosage Escalation at EachTimepoint Placebo/ Adalimumab Adalimumab 40 mg eow 40 mg eow (n = 18) (n= 12) Week 24 10 9 Week 28 2 1 Week 32 2 0 Week 44 1 1 Week 52 3 0 Week60 0 1

Patients whose dosages were increased to weekly dosing had baselinedemographics and clinical characteristics similar to the overall patientpopulation (Table 33).

TABLE 33 Baseline Demographics and Clinical Characteristics for theDosage Escalation Group* Dosage Escalation Group Characteristics (n =30) Age, years 46.5 ± 12.0 Duration of Ps, years 19.2 ± 12.8 % Male 63 %Caucasian 97 Body Weight, kg 97.4 ± 24.2 % BSA ± SD   23 ± 13.8 PASIScore 14.1 ± 6.1  % with PsA 37 *Mean values ± SD except percentages

After qualifying for dosage escalation, nearly 20% of patients achieveda PASI 75 response in their psoriasis at Week 60 (Table 34)

TABLE 34 Efficacy Results at Week 60 for Dosage Escalation Group DosageEscalation Group (n = 30) PASI 50 Response Rate (%) 40 PASI 75 ResponseRate (%) 17 PASI 90 Response Rate (%) 0 PGA (“Clear” or “Almost Clear”)(%) 20 ITT for patients qualifying for dosage escalation. Patients withmissing PASI or PGA evaluations were considered non-responders.FIG. 2 shows the PASI improvement in patients after dosage escalation.

DLQI was evaluated at the time of dosage escalation and at Week 60 for18 of the 30 patients who switched to weekly dosing. Mean improvement inDLQI for these patients was 2.1. One patient in the dosage escalationgroup experienced a serious adverse event, and two others withdrew fromthe study due to adverse events

In conclusion, the majority of psoriasis patients treated withadalimumab eow dosing had a sufficiently satisfactory clinical responseand did not require dosage escalation. Adalimumab 40 mg eow dosingprovided sustained, clinically significant improvement in ˜80% ofpsoriasis patients. mong patients whose dosages increased to 40 mgweekly, 40% achieved PASI 50, and no serious adverse events wereobserved. After qualifying for dosage escalation, nearly 20% of patientsachieved at least 75% improvement in their psoriasis at Week 60.Adalimumab's safety profile in the population of patients who qualifiedfor dosage escalation was consistent with the safety profile ofadalimumab in rheumatoid arthritis clinical trials

Example 6: Achievement of PASI 100 is Associated with BetterDermatology-Specific Patient Reported Outcomes Compared to Achievementof PASI 75-99

Adalimumab is a fully human anti-TNF monoclonal antibody efficacious inthe treatment of psoriasis, based on results from a Phase II clinicalstudy. The present subanalysis was performed to assess if there wasadditional benefit to patients who achieved PASI 100 as compared withthe benefit experienced by patients who achieved PASI 75-99.

The efficacy and safety of adalimumab was evaluated in a 48-weekextension trial conducted at 18 sites in the US and Canada. Prior tothis open-label study, patients were enrolled in a 12-week,double-blind, placebo-controlled trial. Inclusion criteria included:

-   -   ≧18 years of age    -   Moderate to severe chronic plaque psoriasis 1 year    -   Affected BSA 5%        Exclusion criteria included:    -   Prior TNF-antagonist therapy    -   Discontinuation of other systemic psoriasis therapies        Efficacy outcome was measured using PASI and DLQI        responses/scores.

Analytical methods included the following:

-   -   Analyses of clinical data were performed on a modified        intention-to-treat population (ITT). Missing data were analyzed        by non-responder imputation (NRI) for PASI scores. Patients        whose dosages were increased on or after Week 24 were considered        non-responders;    -   Patients with similar percentage PASI improvement across        treatment arms were pooled into four strata: PASI <50, PASI        50-74, PASI 75-99, and PASI 100; and    -   Week-60 distribution of DLQI scores, mean DLQI scores, and mean        change in DLQI from Week 0-60 were calculated within each        stratum.        The study design is shown in FIG. 1, and the baseline        demographics and clinical characteristics are shown in Table 2.

Randomized treatment arms included: 1) placebo (n=52); 2) adalimumab 80mg subcutaneously (sc) at Week 0, then 40 mg sc every other week (eow)starting at Week 1 (n=45); and 3) adalimumab 80 mg sc at Weeks 0 and 1,then 40 mg sc weekly starting at Week 2 (n=50). At Week 12, placebopatients were switched to adalimumab 40 mg eow (placebo eow). Skin andpatient reported outcomes were assessed up to Week 60.

TABLE 35 PASI Response Rates at Week 60 % Treatment Patients PASI 50Placebo/Adalimumab 40 mg eow 57 Adalimumab 40 mg eow 64 Adalimumab 40 mgweekly 66 PASI 75 Placebo/Adalimumab 40 mg eow 45 Adalimumab 40 mg eow56 Adalimumab 40 mg weekly 64 PASI 90 Placebo/Adalimumab 40 mg eow 40Adalimumab 40 mg eow 33 Adalimumab 40 mg weekly 48 PASI 100Placebo/Adalimumab 40 mg eow 19 Adalimumab 40 mg eow 16 Adalimumab 40 mgweekly 26 At Week 12, placebo patients started adalimumab 40 mg eow,after an initial 80-mg dose. Modified ITT, NRI. Patients with PASI <50response on or after Week 24 received open-label adalimumab weeklyrescue therapy. Patients receiving rescue therapy were considerednon-responders in this analysis.

As shown in Table 35, 16-26% of patients who received at least one doseof adalimumab at baseline reported a PASI 100 response at Week 60. Therewere no marked differences in the baseline characteristics betweenpatients with DLQI=0 and DLQI >0 within each PASI stratum, with theexception that a higher percentage of patients with concomitantpsoriatic arthritis reported DLQI=0 (Table 36)

TABLE 36 Baseline Characteristics by DLQI Score Among Key PASI StrataPASI 100 PASI 75-99 DLQI = 0 DLQI > 0 DLQI = 0 DLQI > 0 (n = 23) (n = 6)(n = 20) (n = 34) Age (years) 43.9 44.2 43.5 44.6 % Male 74 83 95 85Body Weight (kg) 94.2 98.2 97.6 100.4 Psoriasis Duration 17.1 23.4 19.920.1 (years) % PsA 22 0 35 18 PASI Score at Baseline 13.3 13.6 17.2 19.3% BSA at Baseline 23 23 29 36 Mean values except percentages

At week 60, PASI 75-99/100 response rates were 38/17 for the(placebo→eow +eow) group and 38/26 for the weekly group (observedanalysis). Pooling patients with similar % PASI improvement acrosstreatment arms, the distribution of DLQI scores (lower score indicatesbetter health status) at week 60 for patients with PASI<50, 50-74,75-99,100 are shown below in Table 37. Pooling across treatment arms, 48of the total 106 patients receiving adalimumab at Week 60 achievedDLQI=0. A majority of patients (79%) with PASI 100 achieved a DLQI=0 atWeek 60 compared with 37% in patients with PASI 75-99 and 28% inpatients with 50-74.

TABLE 37 Number and Percentage of Patients with DLQI Scores of 0, 1, 2,≧3 by PASI Improvement at Week 60 (DLQI Scores By PASI Strata at Week60) PASI Improvement DLQI = 0 DLQI = 1 DLQI = 2 DLQI ≧ 3 Group n (%) n(%) n (%) n (%)  <50 (n = 5) 0 (0)   1 (20.0) 2 (40) 2 (40) 50-74 (n =18)  5 (28) 3 (17) 3 (17) 7 (39) 75-99 (n = 54) 20 (37) 19 (35)  4 (7) 11 (20)   100 (n = 29) 23 (79) 3 (10) 3 (10) 0 (0) Across all PASI strata, DLQI mean scores were substantially lower atWeek 60 (Table 38). At Week 60, patients with PASI <50, 50-74, 75-99,and 100 had mean DLQI scores of 3.0, 3.3, 1.8, and 0.3, respectivelywith mean changes in DLQI from baseline of −6, −8, −11.5, and −11.1,respectively.

TABLE 38 Mean Change in DLQI by PASI Response Rates at Week 60 Mean DLQIat Mean PASI Response Week 60 ΔDLQI PASI <50 −6.0 3.0 PASI 50-74 −8.83.3 PASI 75-99 −11.5 1.8 PASI 100 −11.1 0.3 Observed values. MID^(1,2)(Minimum important difference) = −5 ¹Shikiar R, et al. Health Qual LifeOutcomes 2006, in press. ²Khilji F A, et al. Br J Dermatol 2002, 147: 50(abstract).

Among those PASI 75-99 responders who had DLQI >0 at Week 60,approximately 50% experienced persistent symptoms of itching, soreness,pain, or stinging of the skin and approximately 20% experiencedembarrassment/self-consciousness because of their skin condition.

Withdrawal rates due to adverse events were similarly low in alltreatment groups. All patients treated with adalimumab in theplacebo-controlled study continued into the extension study (Tables 22and 39). The percentage of patients who withdrew due to adverse eventsfrom Weeks 12-60 ranged from 3-10% (Tables 22 and 39). A higherpercentage of patients with PASI 100 and DLQI=0 had adverse events thandid patients with PASI 100 and DLQI >0 (91% vs. 50%), but a lowerpercentage of patients with PASI 75-99 and DLQI=0 had adverse eventsthan did patients with PASI 75-99 and DLQI >0 (80% vs. 91%).

TABLE 39 Adverse Events by Treatment Period Weeks 0-12 Weeks 12-60Adalimumab Placebo/Adalimumab Adalimumab Adalimumab 40 mg 40 mg eow +Adalimumab 40 mg Placebo 40 mg eow weekly 40 mg eow weekly (n = 52) (n =45) (n = 50) (n = 92) (n = 50) Event n (%) n (%) n (%) n (%) n (%) AnyAE 35 (67.3) 28 (62.2) 39 (78.0) 72 (87.3) 39 (78)   Serious 0 (0)   1(2.2) 4 (8.0) 2 (2.2) 7 (14)   AE AEs 1 (1.9) 2 (4.4) 3 (6.0) 3 (3.3) 5(10.0) leading to withdrawl Gordon K B et al., J. Am. Acad. Dermatol.,Published online. DOI: 10.1016/j.jaad.2006.05.027

In sum, approximately 45% of patients receiving adalimumab at Week 60achieved DLQI=0. In this post-hoc subanalysis of a Phase II study,patients who to achieved PASI 100 responses averaged lower DLQI scoresthan patients who achieved PASI 75-99 responses at Week 60. Long-termadalimumab treatment of psoriasis patients provided sustained,clinically significant improvement. Patients who achieved PASI 100typically had superior dermatology-specific patient reported outcomescompared with patients who achieved PASI 75-99. The types and rates ofadverse events in this study were similar to those previously reportedin adalimumab rheumatoid arthritis and psoriatic arthritis trials.

Example 7: Use of TNF Inhibitor in Patients With Hepatitis B Virus

Use of TNF blockers, including Humira, has been associated withreactivation of hepatitis B virus (HBV) in patients who are chroniccarriers of this virus. In some instances, HBV reactivation occurring inconjunction with TNF blocker therapy has been fatal. The majority ofthese reports have occurred in patients concomitantly receiving othermedications that suppress the immune system, which may also contributeto HBV reactivation. Patients at risk for HBV infection should beevaluated for prior evidence of HBV infection before initiating TNFblocker therapy. Prescribers should exercise caution in prescribing TNFblockers for patients identified as carriers of HBV. Adequate data arenot available on the safety or efficacy of treating patients who arecarriers of HBV with anti-viral therapy in conjunction with TNF blockertherapy to prevent HBV reactivation. Patients who are carriers of HBVand require treatment with TNF blockers should be closely monitored forclinical and laboratory signs of active HBV infection throughout therapyand for several months following termination of therapy. In patients whodevelop HBV reactivation, HUM1RA should be stopped and effectiveanti-viral therapy with appro priate supportive treatment should beinitiated. to The safety of resuming TNF blocker therapy after HBVreactivation is controlled is not known. Therefore, prescribers shouldexercise caution when considering resumption of HUMIRA therapy in thissituation and monitor patients closely.

Example 8: The Validity and Responsiveness of Three Quality of LifeMeasures in the Assessment of Psoriasis Patients: Results of a Phase IIStudy

Moderate to severe plaque psoriasis has been demonstrated to havesubstantial impact on function limitations and psychosocial factors ofpatients with the disease [1-5]. Moreover, successful treatment ofmoderate to severe psoriasis—as assessed by improved physicalfunctioning and reduction of signs and symptoms—has been shown to have apositive impact on social and psychological aspects of psoriasis [6-11].

Given the functional and psychosocial impact of the disease, studies ofmoderate to severe psoriasis patients often include bothphysician-assessed clinical endpoints and dermatology-specificpatient-reported outcomes (PROs) to obtain a holistic view of thedisease and treatment effects in patients [12]. Such practices arebolstered by the assertion of the Medical Advisory Board of the NationalPsoriasis Foundation (NPF) that, even more so than physical signs, suchas the percentage of body surface area (BSA) affected by psoriasis, theseverity of psoriasis is “first and foremost a quality-of-life (QOL)issue” [13]. The same values for percentage BSA involvement can resultin very different degrees of impact for different patients, depending onthe location of psoriatic plaques, the pain associated with the lesionsand plaques, the extent of bleeding associated with the psoriaticlesions, and resulting functional limitations. The NPF Advisory Boardsuggests an alternative basis for defining mild, moderate, or severepsoriasis, predicated on QOL impacts of the disease. Similarly, theguidelines recently promulgated by the British Association ofDermatologists [14] for the use of biologics in psoriasis indicate thateligible patients must have a Psoriasis Area and Severity Index

(PASI) score of at least 10 and a score on the Dermatology Life QualityIndex (DLQI) [15] —a dermatology-specific validated PRO measure—ofgreater than 10.

A Phase II clinical trial of two dosages of adalimumab and placebo inthe treatment of moderate to severe psoriasis provided an opportunity tofurther explore the psychometric characteristics—includingresponsiveness and minimum important differences—of the three PROs usedin the trial: the DLQI; the general health-related QOL measure MOS ShortForm 36 (SF-36) Health Survey [16]; and the general health statusmeasure EuroQOL 5D (EQ-5D) [17,18]. Establishing the reliability,validity, and responsiveness of PRO measures is necessary for their usein support of labeling claims, according to an FDA draft guide toindustry [19]. Reliability refers to the accuracy of a measure, whilevalidity refers to the extent the measure actually is measuring what itpurports to measure. Responsiveness is a component of validity andrepresents the PRO' s capability to detect changes related to changes inthe clinical status of patients or other relevant outcomes measuresMinimum important difference (MID) is related to responsiveness andprovides guidance to those reviewing clinical trial results as towhether the statistically significant group differences or changes areclinically meaningful and important. Jaeschke and colleagues [20] definea minimal clinically important difference (MCID) (MID is used hereinstead of MCID to avoid confusion) as “the smallest difference in score. . . which patients perceive as beneficial and which would mandate, inthe absence of troublesome side-effects and excessive cost, a change inthe patient's management.” Estimation of the MID—using several differentapproaches—is also emphasized in the FDA guidance and is consistent withrecently published recommendations of health outcomes researchers[21,22].

The objective of the study was to examine the relationships among theDermatology Life Quality Index (DLQI), the Short Form 36 (SF-36), andthe EuroQOL 5D (EQ-5D) and to assess their validity, responsiveness, andestimates of minimum important differences.

Methods Overview

A Phase II, randomized, double-blind, parallel group,placebo-controlled, multi-center clinical trial assessed the clinicalefficacy and safety of two doses of subcutaneously administeredadalimumab vs. placebo for 12 weeks in the treatment of patients withmoderate to severe plaque psoriasis. This study provided the opportunityto evaluate the validity and responsiveness to change in clinical statusof PROs instruments. Patients completed the DLQI, SF-36, and EQ-5Dquestionnaires at baseline and at 12 weeks. Blinded investigatorsassessed the Psoriasis Area and Severity Index (PASI) scores and thePhysician's Global Assessment (PGA) scores of enrolled patients. Theresponsiveness of the measures to changes in the clinical endpoints frombaseline to Week 12 was assessed. Estimates of minimum importantdifferences (MID) were derived. All analyses were performed with blindeddata; findings and conclusions were not biased based on treatmentcondition.

The objectives of the Phase II, randomized, double-blind, parallelgroup, placebo-controlled, multi-center clinical trial were to assessthe clinical efficacy and safety of subcutaneously administeredadalimumab vs. placebo using two dosage regimens for 12 weeks in thetreatment of patients with moderate to severe plaque psoriasis. Thestudy included a screening period, a blinded 12-week treatment period,and a 30-day follow-up visit for patients not completing 12 weeks ofactive treatment or not entering an extension study. Time betweenscreening and baseline visits was not to to exceed 28 days. The trialfound that adalimumab was both safe and efficacious vs.

placebo in the treatment of moderate to severe, chronic plaque psoriasis[23].

Patients and Inclusion Criteria

Patients with a diagnosis of moderate to severe plaque psoriasis and anaffected BSA of ≧5% for at least 1 year were eligible for the study. Inaddition to other inclusion criteria (e.g., age ≧18 years, willingnessto give informed consent), patients had to be able to self-injectmedication or have a designee or nurse who could inject the randomizedassignment. Patients signed informed consent forms, and the studycomplied with FDA Good Clinical Practices, Health Protection Branchguidelines, and all other applicable ethical, legal, and regulatoryrequirements [23].

Clinical Measures

For purposes of the analyses reported here, there were two primaryclinical outcomes:

Psoriasis Area and Severity Index

Frequently used as an endpoint in psoriasis clinical trials [24], thePASI [25] was the primary efficacy outcome in this trial. PASI is acomposite index indicating the severity of the three main signs ofpsoriatic plaques (i.e., erythema, scaling, and thickness) and isweighted by the amount of coverage of these plaques in the four mainbody areas (head, trunk, upper extremities, and lower extremities). PASIscores range from 0-72, with higher scores indicating greater diseaseseverity. PASI was assessed at screening and baseline, at Weeks 1, 2, 4,8, and 12/Early Termination, and at the final follow-up visit.

Physician's Global Assessment

The PGA is a seven-point scale used to measure the severity of diseaseat the time of the physician's evaluation. The seven disease categoriesare:

-   -   Severe: very marked plaque elevation, scaling, and/or erythema    -   Moderate to Severe: marked plaque elevation, scaling, and/or        erythema    -   Moderate: moderate plaque elevation, scaling, and/or erythema    -   Mild to moderate: intermediate between moderate and mild    -   Mild: slight plaque elevation, scaling, and/or erythema    -   Almost Clear: intermediate between mild and clear    -   Clear: no signs of psoriasis (post-inflammatory hypopigmentation        or hyperpigmentation could be present).

The PGA scale is scored from 1 (Clear) to 7 (Severe). The PGA wasassessed by the investigator at screening, baseline, and Weeks 1, 2, 4,8, 12/Early Termination, and the follow-up visit. Each study site was tomake every attempt to have the same investigator perform theseassessments throughout the study for each patient.

Patient-Reported Outcome Measures

Three PROs measures were used in the study and are the subject of theanalyses reported here. All PROs measures were assessed at baseline andat Week 12 (or early termination, if applicable).

Dermatology Life Quality Index

The DLQI was developed as a simple, compact, and practical questionnairefor use in dermatology clinical settings to assess limitations relatedto the impact of skin disease [15]. The instrument contains 10 itemsdealing with skin (e.g., Item 1: “Over the last week, how itchy sore,painful, or stinging has your skin been?”). The DLQI score ranges from0-30, with “30” corresponding to the worst quality of life, and “0”corresponding to the best score. The DLQI has well-establishedproperties of reliability and validity in the dermatology setting[15,26-28].

Short Form 36 Health Survey

The SF-36 is a 36-item general health status instrument often used inclinical trials and health services research [16]. It consists of eightdomains: Physical Function, Role Limitations—Physical, Vitality, GeneralHealth Perceptions, Bodily Pain, Social Function, RoleLimitations—Emotional, and Mental Health. Two overall summary scores canbe obtained—a Physical Component Summary (PCS) score and a MentalComponent Summary (MCS) score [29]. The PCS and MCS scores range from0-100, with higher scores indicating better health. The SF-36 has beenused in a wide variety of studies involving psoriasis, includingdescriptive studies [30] and clinical research studies [6,7], and hasdemonstrated good reliability and validity. Internal consistency formost SF-36 domains is greater than 0.70. The SF-36 has been shown todiscriminate between known groups in a variety of diseases, isreproducible, and is responsive to longitudinal clinical changes.

EuroQOL 5D

The EQ-5D [17,18] is a six-item, preference-based instrument designed tomeasure general health status. The EQ-5D has two sections: The firstconsists of five items to assess degree of physical functioning(mobility, self-care, usual activities, pain/discomfort, andanxiety/depression). Items are rated on a three-point scale ranging tofrom “No Problem” to “Extreme Problem” or “Unable to Do.” Each patternof scores for the five items is linked to an index score that has avalue ranging from 0-1, indicating the health utility of that person'shealth status. The specific linkage can differ from country to country,reflecting differences in cultures to the item responses. The secondsection is the sixth item on the EQ-5D, which is a visual analog scalewith endpoints of “100” or “Best Imaginable Health,” and “0” or “WorstImaginable Health.” It offers a simple method for the respondents toindicate how good or bad their health statuses are “today.” The score istaken directly from the patients' responses.

Statistical Methods

Validity of the PRO measures was assessed in several ways. First, anassessment was made of the concurrent validity of scales and subscales(i.e., the extent to which PRO measures are correlated with oneanother). As a disease-specific PRO measure, the DLQI was expected tocorrelate moderately to extremely well with general PRO measures.Another important aspect of validity in this study was to assess theextent to which the PRO measures correlated with the clinicalendpoints—PASI and PGA—both at baseline and at Week 12.

Responsiveness of PRO measures was assessed via two approaches. First,changes in these measures from baseline to Week 12 were correlated withchanges in the PASI or PGA over the 12-week course of treatment withinthe trial. Concurrent improvement in both clinical measures and PROmeasures was expected to result in positive correlations. The secondapproach to assessing responsiveness involved categorizing patients intoresponder groups based on the changes in their PASI scores from baselineto Week 12. This was done in two ways. First, a responder was defined asa patient with >75% improvement in PASI (consistent with the definitionof success with the primary efficacy variable), and a non-responder wasdefined as a patient with a PASI improvement <50% (consistent with thedefinition of failure for a secondary efficacy variable). Tests of meandifferences in improvement on the PRO measures were completed betweenthe two groups. Secondly, in support of the estimation of the MID,discussed below, patients were further categorized by degree of PASIresponse, and assessed differences among these four groups: PASIimprovement <25%; PASI improvement 25-49%; PASI improvement 50-74%; andPASI improvement >75%. Analyses of variance tests were performed amongthese four groups for changes in PRO measures.

In accordance with the FDA draft guidance [19] and consistent withrecent recommendations from PRO researchers [21,22], five methods wereused to estimate MIDs of the PROs. The PRO change score corresponding toPASI 25-PASI 49 was the first estimate of MID, called MID-1. This wasbased on the assumption that patients to would perceive a PASIimprovement of 25% as beneficial. The trial did not provide data to testthis assumption (e.g., there was no rating by patients of their overallimprovements). A second estimate, MID-2, was based on the PRO changescore corresponding to a PASI improvement between 50-74%. The PASI 50 isseen as clinically relevant, and, as such, this degree of improvementserved as a secondary efficacy endpoint in this trial. A third methodfor estimating MID relied on the association of changes in the PROmeasure with changes in the PGA. A non-responder was defined as apatient with a PGA change score of either “0” (no change) or “1” (slightincrease in severity of disease) from baseline to Week 12. A minimalresponder was defined as a patient whose PGA improved by either 1 or 2points from baseline to Week 12. The third estimate of MID, MID-3, wasthe difference in the PRO score between non-responders and minimalresponders.

In addition, two distributional methods were used to support theanchor-based MID estimates for the PROs [21,22]. Based on evidence byWyrwich and associates [31,32], the standard error of measurement (SEM)can be used to approximate the MID. The SEM, which describes the errorassociated with the measure, was estimated by the standard deviation ofthe measure multiplied by the square root of 1 minus its reliabilitycoefficient. Finally, there has been discussion [33] concerning a numberof studies demonstrating that one-half of the standard deviation of ameasure represents the upper limit of the MID [22]. In estimating theSEM for the SF-36 and the EQ-5D, reliability estimates from theliterature were used. The SEM for the DLQI incorporated the reliabilityestimated from the trial data, which was consistent with what has beenfound in the literature for this instrument [27].

Finally, it is important to note that all analyses were performed withblinded data (i.e., the statuses of patients with respect to theirassigned treatment groups were not known).

RESULTS Overview

The dermatology-specific DLQI was highly correlated to clinicalendpoints at baseline and at Week 12, and was the most responsive PRO tochanges in endpoints. Compared with the SF-36, the EQ-5D index score andVAS scores were generally more highly correlated with clinicalendpoints, but displayed about the same degree of responsiveness. Themost responsive SF-36 scales were the Bodily Pain and Social

Functioning scales. Estimates of the MID for the DLQI ranged from2.3-5.7 and for the SF-36 Physical Component Summary (PCS) score rangedfrom 2.5-3.9.

Patient Demographics and Clinical Characteristics

A total of 147 patients enrolled and received at least one dose of studymedication at 18 sites in the United States and Canada. Blinded datawere available for the PROs for 147 patients at baseline and 140patients at Week 12. Since the focus of these analyses were on thepsychometric properties of the PROs rather than with efficacy, observedcases were employed rather than last observation carried forward orother methods for treating missing observations at the end of trial. Themean age of the patients enrolled in the trial was 44.2 years,two-thirds were male, and the preponderance were white (Table 40).

TABLE 40 Baseline Demographic Characteristics Characteristic (N = 147)Age Mean (SD) 44.2 (12.7)   Gender Female n (%) 48 (32.7%) Male n (%) 99(67.3%) Race White n (%) 133 (90.5%)  Black n (%) 4 (2.7%) Asian n (%) 5(3.4%) Other n (%) 5 (3.4%)

Clinical Endpoints

The results for the PASI and the PGA at baseline and Week 12, as well asthe change from baseline to Week 12, are displayed in Table 41. The meanPASI at baseline was 15.7, which decreased by 8.9 points (improvement)to 6.8 by Week 12. The mean PGA at baseline was 5.5 (i.e., midwaybetween “Moderate” and “Moderate to Severe”), and decreased (improved)by 2.1 points to 3.4 by Week 12 (i.e., between “Mild” and

“Mild to Moderate”). In evaluating the improvement in the two clinicalendpoints, it is important to keep in mind that these analyses includedpooled placebo and active treatment groups.

TABLE 41 Mean (Standard Deviation) of PASI and PGA at Baseline and Week12, and Change from Baseline to Week 12 Measure Baseline Week 12 Change²PASI 15.69 (7.34) 6.84 (7.77) −8.87 (8.41) PGA¹  5.48 (0.81) 3.36 (1.74)−2.14 (1.87) ¹Scored such that 1 = “Clear” to 7 = “Severe.” ²Changescores are computed only for the 140 patients with scores at baselineand Week 12; sample size at baseline = 147.

Patient-Reported Outcome Measures

The results for the DLQI, SF-36, and EQ-5D at baseline and Week 12, andthe change from baseline are shown in Table 42. Based on blinded data,mean PRO measures improved during the course of the trial (a decrease inDLQI scores indicates an improvement; an increase in the SF-36 and EQ-5Dindicates improvement). The greatest improvement in a DLQI item occurredfor the first item, assessing how “itchy, sore, painful, or stinging”the person's skin felt. Similarly, as shown in Table 19, the greatestimprovement among the SF-36 scales was for Bodily Pain, although therewere improvements in each of the SF-26 scales using adalimumab treatmentfor psoriasis. The largest improvement among the five EQ-5D dimensionsoccurred for the Pain/Discomfort dimension. Given these findings, itappears that improvement in pain and discomfort is the most pronouncedamong all PRO measures assessed.

TABLE 42 Mean (Standard Deviation) of PROs at Baseline and Week 12, andChange from Baseline to Week 12 Measure Baseline Week 12 Change¹ DLQITotal Score 12.71 (7.18)  5.28 (6.49) −7.45 (7.78) SF-36 PhysicalFunctioning 79.26 (24.95) 84.43 (22.62) 5.63 (22.25) Role-Physical 72.45(37.56) 82.50 (34.67) 9.64 (40.30) Bodily Pain 59.58 (25.37) 75.87(24.89) 16.59 (26.90) General Health 66.7 (20.6) 72.69 (20.79) 6.10(16.25) Vitality 53.89 (22.81) 61.04 (23.18) 7.60 (20.88) SocialFunctioning 74.49 (27.56) 85.98 (23.63) 11.16 (27.80) Role- Emotional76.03 (35.39) 85.48 (30.77) 8.39 (37.02) Mental Health 69.39 (19.30)77.43 (17.73) 8.14 (18.57) Physical Summary 47.93 (10.23) 51.24 (9.51) 3.47 (9.30) Score (PCS) Mental Summary 47.30 (11.23) 51.36 (10.08) 3.94(11.04) Score (MCS) EQ-5D Index Score 0.66 (0.28) 0.82 (0.23) 0.16(0.29) VAS Overall Health 72.25 (20.67) 81.22 (17.26) 9.35 (20.71)¹Change scores are computed only for patients with scores at baselineand Week 12; this number varied between 138 and 140, depending on thespecific measure, as compared with the 147 patients at baseline.

The reliability of the DLQI, as assessed by coefficient alpha, was 0.89at baseline and 0.92 at Week 12, indicating that this is a highlyreliable measure, and in line with previous findings [27, 28].

Relationships Among Patient-Reported Outcome Measures

Table 43 displays the correlations among PRO measures at baseline and atWeek 12, as well as the correlations among changes in these measuresfrom baseline to Week 12. There were a few trends evident form thisdata. First, all measures were statistically significantlyinter-correlated. Second, with respect to the relationship between theDLQI and the SF-36, the DLQI correlated the greatest with the BodilyPain and Social Functioning domains, both at baseline and at Week 12,and, for changes in these scores over the course of the trial. Third,the DLQI correlated highly with the EQ-5D index score, and thesecorrelations were consistently higher than the correlations with theEQ-5D visual analog scale (VAS) scores. Fourth, the EQ-5D index scoretended to correlate greatest with the Bodily Pain domain of the SF-36.Finally, the scores tended to be more highly correlated at the end ofthe trial than at baseline, consistent with previous findings [28].

TABLE 43 Correlations¹ among PROs at Baseline and Week 12, and Changefrom Baseline to Week 12 Week 12 Change Baseline EQ- EQ- EQ- DLQI EQ-5DEQ-5D DLQI EQ-5D 5D DLQI 5D 5D Measure Total Index VAS Total Index VASTotal Index VAS DLQI 1.00 −0.51 −0.35 1.00 −0.71 −0.58 1.00 −0.53 −0.46Total Score SF-36 Physical −0.44 0.58 0.35 −0.41 0.61 0.49 −0.29 0.470.32 Functioning Role - Physical −0.45 0.64 0.38 −0.57 0.67 0.50 −0.470.51 0.45 Bodily Pain −0.55 0.73 0.45 −0.61 0.76 0.56 −0.66 0.64 0.53General Health −0.24** 0.39 0.47 −0.38 0.59 0.69 −0.33 0.46 0.46Vitality −0.31 0.43 0.48 −0.43 0.62 0.60 −0.46 0.37 0.48 Social −0.690.52 0.46 −0.68 0.74 0.60 −0.68 0.50 0.56 Functioning Role - Emotional−0.41 0.45 0.42 −0.56 0.67 0.53 −0.50 0.41 0.48 Mental Health −0.44 0.460.50 −0.56 0.66 0.67 −0.52 0.49 0.56 Physical −0.41 0.64 0.36 −0.46 0.650.52 −0.41 0.56 0.39 Summary Score (PCS) Mental Summary −0.45 0.39 0.49−0.58 0.66 0.63 −0.59 0.42 0.57 Score (MCS) EQ-5D Index Score −0.51 1.000.39 −0.71 1.00 0.63 −0.53 1.00 0.39 VAS-General −0.35 0.39 1.00 −0.580.63 1.00 −0.46 0.39 1.00 Health ¹All correlations were significant at p< 0.001, unless otherwise noted. *p ≦ 0.05, **p ≦ 0.01, ns =non-significant.Correlations with Clinical Endpoints

Table 44 displays correlations of PRO measures with the two clinicalassessments—PASI score and PGA—at baseline (first two columns of data)and at Week 12 (second two columns). In addition to almost uniformlygreater correlations at Week 12 vs. at baseline—consistent with previousfindings [28]—one can also note that both the DLQI and EQ-5D index scoretended to be more highly correlated with the to two clinical endpointsthan any of the SF-36 domains. The SF-36 scales with the strongestassociation with clinical endpoints are Social Functioning and BodilyPain.

TABLE 44 Correlations¹ between PROs and Clinical Endpoints at Baselineand Week 12, and Change from Baseline to Week 12 Baseline Week 12 ChangeMeasure PASI PGA PASI PGA PASI PGA DLQI 0.31 0.29 0.67 0.65 0.69 0.71Total Score SF-36 Physical −0.32 −0.14 ns −0.28 −0.25** −0.38 −0.14 nsFunctioning Role - −0.22** −0.14 ns −0.41 −0.37 −0.42 −0.31 PhysicalBodily Pain −0.36 −0.19* −0.47 −0.42 −0.60 −0.44 General −0.08 ns  0.05ns −0.34 −0.33 −0.34 −0.24** Health Vitality −0.15 ns −0.06 ns −0.37−0.37 −0.38 −0.31 Social −0.23** −0.21** −0.46 −0.38 −0.44 −0.43Functioning Role - −0.16 ns −0.06 ns −0.37 −0.29 −0.39 −0.36 EmotionalMental −0.17* −0.09 ns −0.46 −0.38 −0.43 −0.36 Health Physical −0.28−0.13 ns −0.35 −0.33 −0.45 −0.25** Summary Mental −0.12 ns −0.08 ns−0.44 −0.36 −0.40 −0.42 Summary EQ-5D Index Score −0.40 −0.31 −0.60−0.51 −0.57 −0.44 VAS- −0.24** −0.09 ns −0.52 −0.43 −0.43 −0.38 GeneralHealth PASI 1.00 0.59 1.00 0.83 1.00 0.75 ¹All correlations weresignificant at p < 0.001, unless otherwise noted. *p ≦ 0.05, **p < 0.01,ns = non-significant.

Responsiveness of the Patient-Reported Outcome Measures

An important attribute for a PRO measure is responsiveness to change inthe clinical status of a patient (i.e., as a patient's disease improves,the PRO measures also improve). The last two columns of Table 44 displaythe correlations between changes in PRO measures used in the trial andchanges in PASI scores and the PGA from baseline to Week 12. These datademonstrate that the DLQI is the most responsive of the PRO to measures.The correlations between changes over the course of the trial in theDLQI total score and changes in the PASI score (r=0.69, p<0.001) and PGA(r=0.71, p<0.001) approach the correlation between changes in the twoclinical measures themselves (r=0.75, p<0.001). In addition, the DLQI isthe only one of the PRO measures to demonstrate equal responsiveness toPGA and PASI scores. The correlation between changes in the EQ-5D indexscore and the two clinical assessments was r=−0.57 (p<0.001) for changesin the PASI to r=−0.44 for changes in the PGA (p<0.001). Similarly, thecorrelations between changes in all but one of the SF-36 scores andchanges in the PGA were smaller than correlations between changes in theSF-36 and the PASI.

A second way to assess responsiveness was to contrast patients who weredefined as clinical responders with those characterized asnon-responders. Given that the primary endpoint in the trial was definedas the percentage of patients achieving a PASI 75 response (i.e., >75%improvement in PASI from. baseline) by Week 12, a responder was definedas a patient with a PASI75 response. A non-responder was a patient with<PASI 50, since some of the secondary endpoints in the trial used thiscut-off. The results of these analyses are displayed in Table 45. DLQItotal scores for responders improved by 12.17 points, while scores ofnon-responders improved by 1.77 points. This difference wasstatistically significant (t=9.0; p<0.0001). All the PRO measures exceptfor the SF-36 Physical Functioning domain were responsive, as defined bya statistically significant difference between responders andnon-responders. The DLQI was the most to responsive of the PRO measures,as evidenced by the size of the t-statistic and the effect size. Theresponsiveness of the EQ-5D index and VAS scores were generally the sameas several of the SF-36 domain scores.

TABLE 45 Change in PRO Measures among Responder¹ Groups Mean Change MeanChange Score Score for for Non- Change in Responders Responders EffectMeasure (n = 66) (n = 53) Difference t-value P Value Size DLQI Total−12.17 (6.78)  −1.77 (5.52)  −10.39 9.0 <.0001 0.40 Score SF-36 Physical 9.12 (23.50)  3.52 (20.19) 5.59 1.4 0.1724 0.01 Functioning Role -Physical 20.08 (35.69) −5.19 (44.76) 25.26 3.4 0.0008 0.08 Bodily Pain26.47 (27.40)  4.21 (22.74) 22.26 4.7 <.0001 0.15 General  8.87 (15.62) 1.47 (17.77) 7.39 2.4 0.0178 0.04 Health Vitality 13.01 (22.58)  1.13(18.20) 11.87 3.1 0.0024 0.07 Social 21.59 (28.13) −2.59 (25.04) 24.194.9 <.0001 0.16 Functioning Role - 19.70 (32.54) −9.62 (36.95) 29.31 4.6<.0001 0.14 Emotional Mental Health 14.55 (17.77) −0.38 (18.15) 14.924.5 <.0001 0.14 Physical 5.35 (9.67) 1.47 (9.08) 3.88 2.2 0.0287 0.03Summary Score (PCS) Mental  8.03 (10.59) −2.03 (10.42) 10.06 5.1 <.00010.17 Summary Score (MCS) EQ-5D Index Score 0.25 (0.30) 0.04 (0.26) 0.224.2 <.0001 0.12 VAS General 15.69 (18.96)  1.92 (23.24) 13.77 3.5 0.00060.09 Health ¹Responder is defined as PASI improvement ≧75%;non-responder is defined as PASI improvement<50

While the estimates of responsiveness displayed in the last two columnsof Table 44 take into account the full range of PASI change scores andtheir relationship to PRO change scores, the responsiveness analysis inTable 45 places patients in two categories—responders andnon-responders. Table 46 defines four categories of responders:responders, defined as those with PASI improvements ≧75%; “partialresponders,” those with PASI improvement 50-74%, inclusively; “nearresponders,” those with PASI to improvement 25-49%, inclusively; andnon-responders, with <PASI25. One-way analyses of variance wereperformed among these groups for each of the PRO measures. As can beseen by the size of the f-statistics, the DLQI was the most responsiveof the PRO measures. In fact, only the DLQI was able to demonstratestatistically significant differences between responders and partialresponders based on post-hoc significance tests among the four respondergroups. These results for the DLQI total score with respect todifferences among responder groups were similar to those reportedpreviously in the literature, except that the improvement in DLQI totalscores displayed in Table 40 was larger for each of the responder groupsthan for the equivalent responder groups described by Shikiar andcolleagues in a study of efalizumab [28]. As was the case for the datadisplayed in Table 45, the responsiveness of the EQ-5D index and VASscores were generally the same as for most of the SF-36 scores. Finally,both the SF-36 MCS and PCS scores were responsive, but the MCS was moreresponsive, indicating that the impact of the disease was both physicaland mental, with the latter perhaps being more prominent for this studypopulation.

TABLE 46 PRO Change Scores Corresponding to Levels of PASI ImprovementPASI PASI PASI PASI Improvement Improvement Improvement Change inImprovement 25-49% 50-74% ≧75% Overall Measure <25% (n = 31) (n = 22) (n= 21) (n = 66) F Value p Values¹ DLQI Total −0.16 (5.41)  −4.05 (4.95) −6.95 (5.71)  −12.17 30.4***  2**, 3***, Score (6.78) 5***, 6* SF-36Physical  2.15 (17.67)  5.45 (23.60)  0.02 (22.36) 9.12 1.2  Functioning (23.50) Role - Physical −11.29 (39.18)   3.41 (51.35) 14.29(31.20) 20.08 4.9**  3** (35.69) Bodily Pain −1.03 (21.42) 11.59 (22.96)16.76 (22.74) 26.47 9.0*** 3*** (27.40) General −0.61 (17.33)  4.41(18.37)  9.19 (11.29) 8.87 2.8*  Health (15.62) Vitality −1.45 (16.29) 4.77 (20.44)  6.90 (17.43) 13.01 3.8*  3* (22.58) Social −3.23 (23.71)−1.70 (27.36) 13.10 (17.44) 21.59 8.7*** 3***, 5** Functioning (28.13)Role - −11.11 (36.44)  −7.58 (38.40) 17.46 (34.35) 19.70 7.6*** 2*, 3**,Emotional (32.54) 5* Mental Health −0.77 (18.08)  0.18 (18.66)  9.52(13.53) 14.55 7.2*** 3**, 5* (17.77) Physical −0.31 (7.18)   3.91(10.88) 2.57 (7.78) 5.35 2.7*  Summary (9.67) Mental −2.19 (9.86)  −1.82(11.38) 6.05 (6.90) 8.03 9.9*** 2*, 3***, Summary (10.59) 5** EQ-5DIndex Score −0.01 (0.26)  0.10 (0.24) 0.20 (0.21) 0.25 7.1*** 3***(0.30) VAS General  0.58 (24.31)  3.82 (22.07)  8.43 (11.24) 15.694.8**  3** Health (18.96) Mean PASI 0.94 (4.07) −6.24 (2.99)  −8.94(3.47)  −14.33 Improvement² (7.65) ¹Pairwise comparisons between meanswere performed using Scheffe's test adjusting for multiple comparisons.1 = improvement <25% vs. improvement 25-49%, 2 = improvement <25% vs.improvement 50-74%, 3 = improvement <25% vs. improvement ≧75%, 4 =improvement 25-49% vs. improvement 50-74%, 5 = improve 25-49% vs.improvement ≧75%, and 6 = improvement 50-74% vs. improvement ≧75%. *p <0.05, **p < 0.01, ***p < 0.001. ²Negative change scores indicateimprovement

Estimates of Minimum Important Differences

There is no one best way to estimate the MID for a PRO measure [21,34].Table to 47 contains three different anchor-based methods for estimatingthe MID based on data from this study. MID-1 contains the estimateobtained from the scores from the “near-responders,” shown as the PASI25-PASI 49 group in Table 46; MID-2 contains the estimate correspondingto “partial responders” in the same table 40. MID-3 corresponds to thedifference between non-responders for the PGA (defined as patients whohad no change in score or a decrease in score by one point on this7-point scale) and minimal responders for this same measure (defined aspatients who improved by 1 or 2 points). The distribution-basedestimates, the SEM and one-half the standard deviation of baselinescores are also reported in Table 47.

TABLE 47 Estimates of MCID for PRO Measures MID-3: Difference BetweenMID-1: PASI MID-2: PASI Non-Responders (n = 34) and Change inImprovement Improvement Minimal Responders (n = 41) Measure 25-49%50-74% on PGA SEM 0.5 SD DLQI Total −4.05 (4.95) −6.95 (5.71) −5.69 2.333.59 Score SF-36 Physical N/A N/A N/A N/A N/A Functioning¹ Role- 3.41(51.35) 14.29 (31.20) 10.51 15.02 18.78 Physical Bodily Pain 11.59(22.96) 16.76 (22.74) 9.05 10.76 12.69 General 4.41 (18.37) 9.19 (11.29)4.97 9.67 10.31 Health Vitality 4.77 (20.44) 6.90 (17.43) 6.54 8.2211.40 Social −1.70 (27.36) 13.10 (17.44) 13.62 10.67 13.78 FunctioningRole- −7.58 (38.40) 17.46 (34.35) 24.71 14.59 17.70 Emotional Mental0.18 (18.66) 9.52 (13.53) 4.90 6.10 9.65 Health Physical 3.91 (10.88)2.57 (7.78) 0.51 2.71 5.12 Summary Score (PCS) Mental −1.82 (11.38) 6.05(6.90) 6.61 3.89 5.61 Summary Score (MCS) EQ-5D Index Score 0.10 (0.24)0.20 (0.21) 0.09 0.22 0.14 VAS- 3.82 (22.07) 8.43 (11.24) 4.59 N/A 10.34General Health Note: MID-1 corresponds to the score for the PASI 25-49group; MID-2 corresponds to the score for the PASI50-74; for MID-3 andMID-4, reliability estimates for computing SEM were obtained from thedata in this study for the DLQI and from estimates found in theliterature for the SF-36 and EQ-5D. ¹MID estimates are not provided forthe SF-36 Physical Function domain since there were not significantdifferences among responder groups.

Estimates for the DLQI MID ranged from 4.05 (for MID-1) to 6.95 (forMID-2), while the SEM was 2.33 and one-half standard deviation was 3.59.The MID results for the SF-36 PCS ranged from 0.51 (for MID-3) to 3.91(for MID-1), with the SEM estimated as 2.71 and one-half standarddeviation estimates as 5.12. For the MCS, the

MID estimates included a decrease of 1.82 points based on a PASIimprovement of 25-49%, but the other two MIDs were 6.05 and 6.61,respectively. The SEM for the MCS was 3.89 and one-half standarddeviation was 5.61. Consistent with the MCS findings, decreases wereobserved for the Role—Emotional and Social Functioning domains for theto MID-1 definition. The differences between non-responders and minimalresponders ranged from 4.90 for Mental Health to 24.71 for SocialFunctioning (Table 47). The results for the EQ-5D index scoredemonstrated an MID ranging from 0.09 (for MID-3) to 0.20 (for MID-2).For the EQ-5D VAS, the available estimates ranged from 3.82 (MID-1) to8.43 (MID-3).

Discussion

A Phase II randomized clinical trial of adalimumab in moderate to severeplaque psoriasis provided the opportunity to evaluate the validity andresponsiveness to clinical change of three PRO assessmentinstruments—one dermatology-specific instrument and two general healthstatus instruments—all used as endpoints in the study. All analyses wereperformed on a blinded basis, since the main focus of these secondaryanalyses was on the psychometric qualities of the PRO instruments.

The present study further establishes the reliability and validity ofthe DLQI and its responsiveness to change in the clinical status ofpatients over the course of a 12-week clinical trial, confirmingprevious findings [28]. Changes in the DLQI total score demonstratedsignificant and sizeable correlations with independently obtainedphysician-assessed changes in the clinical statuses of patients. Thisindicates that the alleviation of psoriatic signs, as determined byclinical assessments, results in significant and marked improvement indermatologic-related functional limitations and quality of life inpatients with moderate to severe plaque psoriasis. Based on this study,the DLQI is a psychometrically sound and responsive measure ofpsoriasis-specific outcomes that captures more comprehensively theimpact of clinical signs and symptoms on patient well-being.

We used both the PASI and the PGA, as well as two distributionalapproaches to derive estimates of the MID of the DLQI. These estimatesranged from 2.33-6.95, although the PASI 50 was too conservative forestimating the minimum change that patients will find beneficial.Therefore, we the estimate based on PASI improvement of 25-49% orbetween non-responders and minimal responders provided a better estimateof MID for this study. Therefore, the results indicate that the MID isin the range of approximately 2.3-5.7, which is slightly higher than therange of estimates derived from Shikiar et al. [28] in an analysis oftwo clinical trials involving another psoriasis therapy. Thedistributional approaches resulted in the lowest estimates of MID forthe DLQI, but it should be noted that the distributional approach toestimating the MID is considered supportive of the anchor-based methods[22,35]. For example, the one-half standard deviation estimate iscertainly clinically meaningful, but is likely not a minimum magnitudeof change. Finally, the range of estimates incorporates another previousestimate of the MID of the DLQI of 5.0 [36].

Two general PRO measures were used in this study. In general, the EQ-5Dindex and VAS scores demonstrated higher correlations than the SF-36scale scores with the clinical endpoints (Table 42). However, theresponsiveness of these two EQ-5D scores were generally the same as theresponsiveness of most of the SF-36 scores. Although most of the SF-36scores showed improvements associated with clinical outcomes, the MCS,Social Functioning, and Role-Emotional domain scores demonstrateddecreases in the PASI 25-49% group. These findings may have been drivenby several outliers and the relatively small sample size for this group.Alternatively, given that Bodily Pain and other physical domains may bemore related to the signs and symptoms of psoriasis thanRole—Limitations and Social Functioning, small improvements in PASIscores may not be directly associated with changes in these PRO domains.That is, larger changes in clinical outcomes may be needed tosignificantly impact the areas of physical function and well-being. Thisidea seems to be supported by the observed changes in the PASI 50-74%and other analyses. However, the SF-36 domain and summary scoresdemonstrated consistently reasonable validity and were correlated withclinical endpoints and DLQI scores.

The SF-36 PCS and MCS scores demonstrated good evidence of validity andresponsiveness in this sample of patients with moderate to severe plaquepsoriasis. There were demonstrable associations between changes in PASIscore categories and changes in PCS scores, with the largestimprovements seen in the PASI75 responder groups. The MID estimates forthe PCS were in the range of 0.51-3.91, with the best estimate atapproximately 2.5 points. The SEM estimate (2.71) also supports thisrange of MID values for the PCS. The MID findings for the MCS weresomewhat weaker, but there is evidence that a change of 4-6 points iscertainly clinically meaningful. The MID for the EQ-5D index score wasin the range of 0.09-0.22. Given the impact of psoriasis on thefunctional ability of patients the importance attached to assessingphysical function in psoriasis patients, the results of the presentstudy provide positive support for the use of a dermatology-specifichealth-related PRO measure, the DLQI, in the assessment of psoriasis andresponses to treatment. In addition, the correlation of SF-36 and DLQIindicates that disease-related changes in the SF-36 are largelydependent on two specific domains, Bodily Pain and Social Functioning.It appears that the DLQI total score, as a single index score,adequately captures the functional and psychosocial impact of moderateto severe plaque psoriasis. Further, the DLQI does so in a way that ismore responsive than the general health-related quality of life measuresused to assess changes in patients' underlying clinical statuses.

In conclusion, the findings of this study highlight the importance ofcapturing PRO measures in clinical trials of moderate to severe plaquepsoriasis. This analysis provides additional evidence supporting thepsychometric qualities and responsiveness of the DLQI as adisease-specific measure of PROs in psoriasis. The DLQI MID wasdetermined as ranging from 2.3-5.7 points. The study further shows thatadalimumab was effective at improving DLQI, SF-36, and EQ-5D scores inpatients with psoriasis.

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Example 9: Adalimumab Efficacy and Safety Compared with Methotrexate andPlacebo in Patients with Moderate to Severe Psoriasis

The following study was the first to directly compare the clinicalefficacy, safety, and tolerability of a biologic (adalimumab) vs. atraditional systemic agent (methotrexate or MTX) in the treatment ofmoderate to severe chronic plaque psoriasis. A published internationalconsensus statement recommends that for patients with moderate to severepsoriasis, “equal consideration” should be given to traditional systemictherapy (e.g., MTX, phototherapy, or biologics) (Sterry et al. Brit JDermatol. 2004;151(Suppl 69):3-17). Resistance to using biologics asfirst-line therapy has rested in part on the absence of datademonstrating superiority of a biologic to a traditional systemic agentin a direct, head-to-head study.

The objective of this study was to compare the clinical efficacy,safety, and tolerability of adalimumab vs. MTX and vs. placebo in thetreatment of moderate to severe chronic plaque psoriasis

The study was a multi-center,16-week, randomized controlled Phase IIItrial. to The study design is shown in FIG. 3. The main inclusioncriteria included:

-   -   Clinical diagnosis of psoriasis for 1 year    -   Affected body surface area (BSA) 10%    -   Psoriasis Area and Severity Index (PASI) ≧10        The main exclusion criteria was previous use of MTX or systemic        anti-TNF therapy. The study required a washout period, including        the following:    -   2 weeks for topical and phototherapy    -   4 weeks for non-biologic systemic therapies    -   12 weeks for biologic therapies        Efficacy was measured according to the following:    -   PASI, PGA (Physician's Global Assessment)    -   Primary endpoint was PASI 75 response rate at Week 16        Safety measures was examined using adverse events and laboratory        parameters

The adalimumab dosage regimen (subcutaneous) included an 80 mg (two 40mg injections) at Week 0 (baseline), followed by 40 mg every other week(eow) from Week 1 until Week 15. The MTX dosage regimen included thefollowing:

-   -   7.5 mg at Weeks 0 and 1 (weekly MTX dose adjusted to ALT, AST,        WBC count, platelet count and serum creatinine from Week 2 until        Week 15, and reduced or withheld if deemed appropriate by the        safety assessor);    -   10 mg at Weeks 2 and 3 (weekly MTX dose adjusted to ALT, AST,        WBC count, platelet count and serum creatinine from Week 2 until        Week 15, and reduced or withheld if deemed appropriate by the        safety assessor);    -   15 mg from Weeks 4-15 (Weekly MTX dose increased to 20 mg at        Week 8, 25 mg at Week 12 if PASI <50 and there were no safety        concerns).

Analytical methods included the following:

-   -   Intention-to-treat analyses were performed for all randomized        patients    -   Missing data were analyzed using non-responder imputation (NRI)    -   PASI 75 at Week 16 (primary endpoint) was analyzed using        adjusted Cochran-Mantel-Haenszel test.

Baseline characteristics were similar across treatment groups andconsistent with expectations for patients with moderate to severechronic plaque psoriasis (Table 48)

TABLE 48 Baseline Demographics and Clinical Characteristics Placebo MTXAdalimumab (N = 53) (N = 110) (N = 108†) Age (yrs) 40.7 ± 11.43 41.6 ±11.98 42.9 ± 12.57 Duration of Psoriasis 225.3 ± 104.2  226.5 ± 122.1 214.8 ± 121.1  (mos) % Male 66.0 66.4 64.8 Body Weight (kg) 82.6 ± 19.9183.1 ± 17.50 81.7 ± 19.98 % BSA 28.4 ± 16.09 32.4 ± 20.60 33.6 ± 19.88PASI score 19.2 ± 6.89  19.4 ± 7.39  20.2 ± 7.53  % with Psoriatic 20.817.3 21.3 Arthritis *Mean values ± SD except % Male and % with PsoriaticArthritis. †One patient was withdrawn before receiving any studymedication.

PASI 75 response rate for adalimumab-treated patients was significantlysuperior to PASI 75 response rates for MTX-treated and placebo-treatedpatients at Week 16 (primary endpoint) (Table 49).

TABLE 49 PASI 75 Response Rates n Treatment % Patients Week 4 53 Placebo4 110 Methotrexate 3 108 Adalimumab  23*† Week 8 53 Placebo 13  110Methotrexate 9 108 Adalimumab 62‡ Week 12 53 Placebo 15  110Methotrexate 25  108 Adalimumab 77‡ Week 16 53 Placebo 19  110Methotrexate 36  108 Adalimumab 80‡ *p = 0.001, †p < 0.001, both vs.placebo; ‡p < 0.001 vs. MTX. ITT, patients with missing PASI scores wereconsidered non-responders

TABLE 50 PASI 90 Response Rates n Treatment % Patients Week 4 53 Placebo0 110 Methotrexate 1 108 Adalimumab  7* Week 8 53 Placebo 4 110Methotrexate 3 108 Adalimumab  27†‡ Week 12 53 Placebo 8 110Methotrexate 9 108 Adalimumab  48†‡ Week 16 53 Placebo 11  110Methotrexate 14  108 Adalimumab  52†‡ *p < 0.05 vs. MTX; †p < 0.001 vs.placebo; ‡p < 0.001 vs. MTX. ITT, patients with missing PASI scores wereconsidered non-responders.

Adalimumab-treated patients achieved a significantly superior PASI 90response rate vs. MTX-treated and placebo-treated patients at Week 16(Table 50). Mean percentage PASI improvement for adalimumab-treatedpatients was rapid, with a mean percentage PASI improvement of 57%achieved at Week 4 (FIG. 4). The percentage of adalimumab-treatedpatients who achieved PGA “Clear” or “Minimal” was similar to to thepercentage of adalimumab-treated patients who achieved PASI 75 orgreater improvement (Table 51).

TABLE 51 PGA “Clear” or “Minimal” Responses n Treatment % Patients Week4 53 Placebo 0 110 Methotrexate 1 108 Adalimumab  7*† Week 8 53 Placebo4 110 Methotrexate 3 108 Adalimumab  27‡§ Week 12 53 Placebo 8 110Methotrexate 9 108 Adalimumab  48‡§ Week 16 53 Placebo 11  110Methotrexate 14  108 Adalimumab  52‡§ *p < 0.01 vs. placebo; †p < 0.01vs. MTX; ‡p < 0.001 vs. placebo; §p < 0.001 vs. MTX. ITT, patientsmissing PGA scores were counted as not achieving PGA “Clear” or“Minimal”.

There were no significant differences in the incidences of adverseevents reported for adalimumab-treated vs. MTX-treated and vs.placebo-treated patients (Tables 52 and 53). The most frequent adverseevents were nasopharyngitis (21-28%) and headache (9-13%) (Table 53)

TABLE 52 Adverse Events Placebo MTX Adalimumab Event, n (%) (N = 53) (N= 110) (N = 107*) Any AE 42 (79) 89 (81) 79 (74) Any SAE 1 (2) 1 (1) 2(2) Any AE leading to 1 (2) 6 (6) 1 (1) discontinuation Any infectiousAE 23 (43) 46 (42) 51 (48) Any infectious SAE 0 (0) 0 (0) 0 (0) *Doesnot include patient who was withdrawn from study before receiving anystudy medication. AE = adverse events. SAE = serious adverse events. SAEwere a calculus of right uretero-pelvic junction in one placebo patient,hepatitis secondary to methotrexate in one MTX patient, pancreatitis inone adalimumab patient, and an increase in a benign ovarian cyst in oneadalimumab patient.

TABLE 53 Common Adverse Events in ≧5% of Patient Population in StudyPlacebo MTX Adalimumab Event, n (%) (N = 53) (N = 110) (N = 107*) Nausea4 (8) 8 (7) 4 (4) Nasopharyngitis 11 (21) 26 (24) 30 (28) Rhinitis 4 (8)4 (4) 3 (3) Viral Infection 1 (2) 6 (6) 0 (0) Gamma- 3 (6) 0 (0) 2 (2)Glutamyltransferase Increased Arthralgia 1 (2) 5 (5) 6 (6) Headache 5(9) 12 (11) 14 (13) Rhinorrhea 3 (6) 0 (0) 3 (3) Pruritus  6 (11) 2 (2)4 (4) *One patient was withdrawn from study before receiving any studymedication.

In conclusion, adalimumab demonstrated significantly superior efficacyin the treatment of moderate to severe psoriasis vs. MTX and vs.placebo - PASI 75 at Week 16: 80% for adalimumab vs. 36% for MTX and vs.19% for placebo. Furthermore, response to adalimumab was rapid.Adalimumab was well-tolerated, with a safety profile in this psoriasistrial comparable to its profile in RA clinical trials. The results ofCHAMPION suggest a paradigm shift in the treatment of moderate to severepsoriasis, from “equal consideration” to “first-line consideration” forbiologics

Example 10: Efficacy and Safety of a 120-Week Open-Label Extension Studyin Patients With Moderate to Severe Chronic Plaque Psoriasis

Psoriasis is a chronic, inflammatory proliferative disease of the skinthat affects 1-3% of general population (Greaves and Weinstein N Engl JMed 1995; 332:581-8). Treatment of moderate to severe psoriasis withsystemic agents such as methotrexate or cyclosporine can be limited bylack of efficacy or precluded by dose dependent side effects, andultraviolet light therapy is often inconvenient

The objective of the following study was to determine the long-term (120weeks) efficacy and safety of adalimumab in patients with moderate tosevere plaque psoriasis.

The study includes a Phase III open-label extension (OLE) study ofadalimumab in which patients with moderate to severe chronic plaquepsoriasis (PASI12, PGA of at least moderate, BSA10%) who completed thelead-in 60-week Phase II adalimumab clinical trials could enroll(described in Examples 1-6, 8, 13 and 14). This example summarizesresults in patients treated with adalimumab eow for up to 120 weeks (upto 60 weeks in the preceding Phase II studies and for up to 72 weeks inthe Phase III extension trial). The 120-week efficacy and safety ofadalimumab 40 mg every other week (eow) was evaluated in an open-labelextension trial (III) that followed a 48-week extension trial (II.B),which was conducted at 18 sites. Prior to the II.B study, patients wereenrolled in a 12-week, double-blind, placebo-controlled trial (ILA).Inclusion criteria included: moderate to severe chronic plaquepsoriasis: 1 year and affected BSA: 5%. Exclusion criteria includedprior TNF-antagonist therapy. As observed analysis was conducted toassess efficacy and safety over the 120-week treatment period.

Patients who had completed the lead-in studies could enroll in theopen-label extension (OLE) trial, during which they received adalimumab40 mg every other week (eow). After 24 weeks of OL therapy, patientswith an inadequate response (<PASI 50 to relative to baseline ofII.A—see Study Design of FIG. 5) could increase to adalimumab 40 mgweekly. PASI responses and PGA scores were analyzed as observed.Patients who underwent dose escalation, and patients randomized at Week0 to adalimumab 40 mg weekly are not included in this analysis. Thus,patients whose dosages increased were counted as non-responders from thetime of dosage escalation. Adverse events were collected throughout the120-week period.

A total of 92 patients were enrolled in Study 1.1 (see FIG. 5) andreceived at least one dose of adalimumab 40 mg eow during the 120-weekobservation period. Baseline demographics and clinical characteristicsfor patients randomized to placebo or to adalimumab 40 mg eow in Study1.1 were typical for patients with moderate to severe chronic plaquepsoriasis (Table 54)

TABLE 54 Baseline Demographics and Clinical Characteristics Adalimumab40 mg eow (n = 92) Age (years) 45.1 Duration of Ps (years) 19.7 % Male70.7 % Caucasian 90.2 Body Weight (kg) 94.7 % BSA 28.6 PASI Score 16.3 %with PsA 29.3 Mean values except % Male, % Caucasian, and % with Ps.

Fifty-three percent (49/92) of patients were evaluable for efficacy andsafety after more than 2 years of continuous adalimumab 40 mg eow dosing(Table 55). Week 0 corresponds to the beginning of adalimumab therapy

TABLE 55 Number of Evaluable Patients Over 120 Weeks Time No. ofEvaluable Patients Week 0 92 Week 4 92 Week 8 91 Week 12 89 Week 16 79Week 24 75 Week 36 64 Week 48 60 Week 60 57 Week 72 52 Week 84 52 Week96 53 Week 108 50 Week 120 49

Among patients who continued to receive adalimumab 40 mg eow, PASIresponses peaked at Week 48 and were generally maintained up to Week 120of adalimumab therapy (Table 56). Among patients who continued toreceive adalimumab 40 mg eow, mean percentage PASI improvement peaked atWeek 36 and was generally maintained to Week 120 (FIG. 6)

TABLE 56 PASI Response Rates Up To Week 120 PASI response % PatientsWeek 12 PASI 50 78.7 PASI 75 56.2 PASI 90 29.2 PASI 100 11.2 Week 24PASI 50 86.7 PASI 75 74.7 PASI 90 52 PASI 100 20 Week 48 PASI 50 96.7PASI 75 81.7 PASI 90 61.7 PASI 100 31.7 Week 72 PASI 50 96.2 PASI 7573.1 PASI 90 53.8 PASI 100 25 Week 96 PASI 50 92.5 PASI 75 75.5 PASI 9052.8 PASI 100 24.5 Week 120 PASI 50 93.9 PASI 75 77.6 PASI 90 53.1 PASI100 28.6 Patients who received OL weekly adalimumab rescue therapy andare not included in the as observed analysis.

The percentage of patients who reported malignant, serious, and seriousinfectious adverse events were low and stable over the surveillanceperiod (Table 57). The malignant adverse event reported was a squamouscell carcinoma of the neck in an ex-smoker who had been noted to havelymphadenopathy at screening. The serious adverse events reported weresquamous cell carcinoma (case described above), fall, and dyspepsia. Nocases of tuberculosis, demyelinating disorder, lupus-like syndrome,lymphoma, or congestive heart failure were noted. The percentage ofpatients who reported malignant, serious, and serious infectious adverseevents were low and stable over the surveillance period. The malignantadverse event reported was a squamous cell carcinoma of the neck in anex-smoker who had been noted to have lymphadenopathy at screening. Theserious adverse events reported were squamous cell carcinoma (casedescribed above), fall, and dyspepsia. No cases of tuberculosis,demyelinating disorder, lupus-like syndrome, lymphoma, or congestiveheart failure were noted.

TABLE 57 Patients Experiencing Adverse Events over 120 Weeks Week 0-24Week 25-48 Week 49-72 Week 73-96 Week 97-120 n = 92 n = 78 n = 62 n = 55n = 53 n (%) n (%) n (%) n (%) n (%) Any AE 69 (75.0) 33 (42.3) 28(45.2) 27 (49.1) 25 (47.2) Serious AEs 2 (2.2) 0 (0.0) 0 (0.0) 0 (0.0) 1(1.9) Infectious AEs 28 (30.4) 22 (28.2) 17 (27.4) 15 (27.3)  7 (13.2)Serious Infectious 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) AEs MalignantAEs 1 (1.1) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) AEs leading to 4 (4.3) 0(0.0) 0 (0.0) 0 (0.0) 0 (0.0) withdrawal

Adverse event profile of adalimumab was stable over the 120-weektreatment period (Table 58). Blood tests were performed undernon-fasting conditions

TABLE 58 Common Adverse Events >5% in Any 24-Week Period Week 0-24 Week25-48 Week 49-72 Week 73-96 Week 97-120 n = 92 n = 78 n = 62 n = 55 n =53 Adverse Events n (%) n (%) n (%) n (%) n (%) Nasopharyngitis 9 (9.8)5 (6.4) 1 (1.6) 3 (5.5) 2 (3.8) Increased triglycerides 7 (7.6) 1 (1.3)1 (1.6) 1 (1.8) 0 (0.0) Headache 7 (7.6) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)Upper respiratory tract 6 (6.5) 3 (3.8) 2 (3.2) 2 (3.6) 0 (0.0)infection Diarrhea 5 (5.4) 1 (1.3) 1 (1.6) 0 (0.0) 3 (5.7)Hypercholesterolemia 4 (4.3) 0 (0.0) 1 (1.6) 3 (5.5) 1 (1.9) Sinusitis 1(1.1) 1 (1.3) 1 (1.6) 3 (5.5) 1 (1-9)

In conclusion, patients with moderate to severe psoriasis achievedsustained efficacy up to Week 120 of treatment with adalimumab. Thetypes of adverse events in this study were similar to those previouslyreported in adalimumab rheumatoid arthritis and psoriatic arthritistrials. The percentage of patients diagnosed with adverse eventsappeared stable over the 120-week observation period

Example 11: Short- and Long-Term Efficacy and Safety of Adalimumab in aPivotal Phase III Study in Adult Patients With Moderate to SevereChronic Plaque Psoriasis

Psoriasis is a chronic, immune-mediated, inflammatory skin disease thataffects 1-3% of general population (Greaves and Weinstein, N Engl JMed.1995; 332:581-8). Treatment of moderate to severe psoriasis withsystemic agents such as cyclosporine or methotrexate can be limited bylack of efficacy or precluded by dose-dependent adverse events. Inaddition, ultraviolet light therapy is often inconvenient.

This example describes a Phase III trial of adalimumab conducted at 81sites, in adult patients with moderate to severe chronic plaquepsoriasis. The objective of the study was to compare the efficacy andsafety of adalimumab with placebo during an initial placebo-controlled,double-blind trial period, and to determine if improvement withadalimumab is sustained during open-label treatment. This study alsosought to determine whether discontinuation of adalimumab therapy isassociated with a loss of adequate clinical response, and to determinethe adverse event (AE) profile of adalimumab-treated patients over a52-week period.

The main inclusion criteria for this study included a clinical diagnosisof psoriasis for ≧6 months and affected body surface area (BSA) 10% andPASI 12. The main exclusion criteria included prior use of systemic orbiologic anti-TNF therapy. The washout period included two weeks fortopical agents and UVB, 4 weeks for PUVA and non-biologic systemictherapies, and 12 weeks for all biologic therapies. The two co-primaryendpoints were:

-   -   Percentage of patients achieving PASI 75 at Week 16    -   Percentage of patients, among Week 33 PASI 75 responders, losing        an adequate response after Week 33, characterized by:        -   PASI<50 (relative to baseline) and        -   At least a 6 point increase in PASI

Safety measures included the following:

-   -   AEs and laboratory parameters    -   Percentages of patients and rates (events/patient-year) of AEs        for adalimumab in Period A were compared with those of placebo        in period A, and with those of adalimumab-treated patients over        the entire 52-week study period

As described in the study design of FIG. 7, there were three treatmentperiods, Periods A, B, and C.

Period A was double-blind, placebo-controlled, and lasted from weeks0-16. During Period A, patients were randomized 2:1 to adalimumab orplacebo. Patients in the adalimumab arm received: Week 0: 80 mgsubcutaneously (sc) and Weeks 1-15: 40 mg every other week (eow). AtWeek 16 patients who achieved >PASI 75 improvement continued into PeriodB, while those patients having <PASI 75 improvement entered the openlabel extension (OLE) study (FIG. 7).

Period B was open-label and lasted from Weeks 17-33. Adalimumab wasadministered at 40 mg every other week (eow) subcutaneously (sc).Patients who achieved ≧PASI 75 response at Week 33 entered Period C.Those who had a PASI 50-<75 response at the end of Period B entered theOLE, while those with a <PASI 50 response discontinued the study.

Period C was a double-blind, placebo-controlled which was held fromweeks 34-52. Patients randomized to adalimumab treatment in Period A andwho achieved >PASI 75 at Week 33 were re-randomized 1:1 to eithercontinue adalimumab 40 mg eow or receive placebo treatment. Patientsrandomized to placebo treatment in Period A and who received adalimumabin Period B, continued adalimumab treatment in Period C if they achieveda ≧PASI 75 in Period B

Various analytical methods were used in the study. Intention-to-treat(ITT) analyses were performed for all randomized patients in Periods Aand C. Binary variables were analyzed with non-responder imputation(NRI) in Period A. In order to assess efficacy beyond Week 16, efficacyoutcomes for all patients who had been randomized to adalimumab at Week0 were assessed in Period B and in the OLE. Week 24 results from NRIanalysis include pooled efficacy outcomes from OLE and Period B. AfterWeek 24, non-overlapping OLE and Period B study visits prevent completepooling of efficacy outcomes. Continuous variables were analyzed asobserved during Period B

Baseline characteristics were similar across treatment groups andconsistent with expectations for patients with moderate to severechronic plaque psoriasis (Table 59)

TABLE 59 Baseline Demographics and Clinical Characteristics PlaceboAdalimumab (N = 398) (N = 814) Age (years) 45.4 ± 13.4 44.1 ± 13.2 %Male 64.6 67.1 % Caucasian 90.2 91.2 Duration of Ps (years)  18.4 ±11.94  18.1 ± 11.91 Body Weight (kg) 94.1 ± 23.1 92.3 ± 22.9 BSA (%) 25.6 ± 14.76  25.8 ± 15.51 PASI Score 18.8 ± 7.09 19.0 ± 7.08 % withPsA 28.4 27.5 Mean values ± SD except % Male, % Caucasian and % withpsoriatic arthritis.

Adalimumab-treated patients achieved rapid, and significantly superior,PASI 75 response rates vs. placebo-treated patients from Week 4, thefirst time point evaluated, and every visit through Week 16 (Table 60).PASI 75 response rates were sustained through open-label treatment toWeek 24. Week 24 results include both Period B and to OLE efficacyoutcomes. Pooling of efficacy outcomes after this time point was notpossible because of disparate Period B and OLE study visit schedules(Table 60).

TABLE 60 PASI 75 Response Rates at Weeks 0-24 n Treatment % PatientsWeek 4 398 Placebo 1.3 814 Adalimumab 18.9* Week 8 398 Placebo 3.0 814Adalimumab 54.1* Week 12 398 Placebo 4.8 814 Adalimumab 67.7* Week 16398 Placebo 6.5 814 Adalimumab 71.0* Week 24 398 Placebo — 814Adalimumab 71.0* *p < 0.001, adalimumab vs. placebo. ITT; Patients withmissing PASI scores were considered non-responders. Week 24 resultsrepresent pooling of efficacy outcomes from Period B and OLE. Weeks 4 to16 were double-blind, placebo-controlled. Week 24 was open-label.

TABLE 61 PASI 100 Response Rates at Weeks 0-24 n Treatment % PatientsWeek 4 398 Placebo 0.3 814 Adalimumab 0.9 Week 8 398 Placebo 0.3 814Adalimumab  7.1* Week 12 398 Placebo 0.3 814 Adalimumab 14.4* Week 16398 Placebo 0.8 814 Adalimumab 20*   Week 24 398 Placebo — 814Adalimumab 22.5* *p < 0.001, adalimumab vs. placebo. ITT; Patients withmissing PASI scores were considered non-responders. Week 24 resultsrepresent pooling of efficacy outcomes from Period B and OLE. Weeks 4 to16 were double-blind, placebo-controlled. Week 24 was open-label.

PASI 100 responses were sustained from Week 16 to Week 24 duringopen-label adalimumab treatment (Table 61).

Only patients who achieved PASI 75 responses entered Period B. Forpatients who entered Period B, mean percentage PASI improvement achievedat Week 16 was maintained throughout Period B (Table 62).

TABLE 62 Mean Percentage PASI Improvement During Period B inAdalimumab-Treated Patients* n % PASI improvement Week 16 574 91.9 Week24 577 91.2 Week 33 551 89.3 *Relative to baseline for patients who wererandomized to adalimumab at Week 0 and entered Period B. As observed.

Clinical characteristics were similar between patients re-randomized toadalimumab and placebo in Period C. The proportion of patients losing anadequate response during Period C was significantly lower for patientsre-randomized to continue adalimumab therapy (Table 63).

TABLE 63 Loss of Adequate Response by Week 52 Treatment n % PatientsPlacebo in 240 28.4 period C Adalimumab 250 4.9* in period C *p < 0.001,adalimumab vs. placebo. Primary endpoint: Proportion of patientsexperiencing an event (loss of adequate response) on or before Week 52.An event was defined as the more stringent of a) a PASI <50 (relative tobaseline) or b) a ≧6 point increase in PASI from weeks 34 to 52 relativeto week 33 ITT; Missing Week 52 PASI assessment imputed as an eventbecause of lack of efficacy or study drug toxicity.

Adalimumab Treatment Group comprised all patients who received at leastone dose of adalimumab, with adverse event rate for this groupcalculated for the entire 52 week study period (See Table 64).Percentages of patients and rates of AEs and of infectious AEs werehigher among adalimumab- vs. placebo-treated patients. The percentage ofpatients with serious AEs was comparable among placebo- andadalimumab-treated patients in Period A (1.8%). The rates of serious AEsin the adalimumab-treated patients of Period A were consistent withserious AE rates throughout the study. The vast majority of InfectiousAEs in Period A were not severe. to Severe infectious AE rates werecomparable between patients receiving adalimumab and those receivingplacebo. Percentages of patients and rates of AEs leading to withdrawalwere lower for adalimumab-treated patients vs. placebo treated patients

TABLE 65 Safety Results Percentage of AEs During Rates of AEs duringPeriod A and for the Period A Adalimumab Treatment Group Period A*Period A* Period A* Period A* Adalimumab Placebo Adalimumab PlaceboAdalimumab Treatment Group† (N = 398) (N = 814) (120.7 PYs) (250.2 PYs)(540.5 PYs) (%) (%) (Event/PY) (Event/PY) (Event/PY) Any AE 55.5 62.2‡4.127 4.616 3.991 Serious AEs 1.8 1.8 0.058 0.068 0.061 SeriousInfectious 1.0 0.6 0.033 0.028 0.022 AEs Infectious AEs 22.4 28.9‡ 0.8781.259 1.203 Severe Infectious 0.8 0.7 0.025 0.036 0.030 AEs AEs leadingto 2.0 1.7 0.124 0.072 0.078 withdrawal *Includes safety data up to 70days after last dose for patients not continuing into Period B.†Includes safety data up to 70 days after last dose of adalimumab forall patients who received at least one dose of adalimumab in REVEAL.Adverse events experienced by patients re-randomized to placebo inPeriod C (within 70 days after last dose of adalimumab in Period B) areincluded in this group. ‡p < 0.05, adalimumab vs. placebo.randomized to placebo in Period C (within 70 days alter last dose ofadalimumab in Period B) are included in this group. ‡p<0.05, adalimumabvs. placebo.

From Table 65 it can be seen that no lymphomas were diagnosed in thisstudy. The percentages of patients with non-melanoma skin cancers andthe percentages of patients with all other types of malignancies(excluding non-melanoma skin cancers and lymphomas) were comparableamong placebo- and adalimumab-treated patients in Period A, and forPeriod A vs. the entire 52-week study. One case of oral candidiasis to(opportunistic infection) was diagnosed, and one case of presumptivetuberculosis (-ve AFB and -ve culture, with clinical course suggestiveof tuberculosis) was diagnosed in a patient who was PPD+ve at baselineand who was non-compliant with INH prophylaxis. No cases of rebound werenoted among patients re-randomized to placebo in Period C.

TABLE 65 Adverse Events of Interest Percentage of AEs during Rates ofAEs during Period A and for the Period A Adalimumab Treatment GroupPeriod A* Period A* Period A* Period A* Adalimumab Placebo AdalimumabPlacebo Adalimumab Treatment Group† (N = 398) (N = 814) (120.7 PY)(250.2 PY) (540.5 PY) % % Event/PY Event/PY Event/PY Tuberculosis (TB) 00 0 0 0.002 Opportunistic 0 0 0 0 0.002 Infections, excluding TBCongestive Heart 0 1 0 0.004 0.002 Failure Allergic Reaction 0 1 0 0.0040.002 Injection Site 5.3 6.9 0.215 0.276 0.017 Reaction Malignancies,0.3 0.2 0.008 0.008 0.004 excluding NMSC + lymphoma Non-melanoma skin0.3 0.5 0.008 0.016 0.013 cancers Lymphoma 0 0 0 0 0 Lupus-like Syndrome0 0 0 0 0 Demyelinating 0 0 0 0 0 Disorder *Includes safety data up to70 days after last dose for patients not continuing into Period B.†Includes safety data up to 70 days after last dose of adalimumab forall patients who received at least one dose of adalimumab in REVEAL.Adverse events experienced by patients re-randomized to placebo inPeriod C (within 70 days after last dose of adalimumab in Period B) areincluded in this group.

From Table 66 it can be seen that during Period A, infectious AEsexperienced by more than 2% of adalimumab-treated patient were upperrespiratory tract infections (7.2%), nasopharyngitis (5.3%), andsinusitis (2.7%). The most common adverse events reported in theAdalimumab Treatment Group were upper respiratory tract infections,nasopharyngitis, and headache.

TABLE 67 Common Adverse Events ≧5%: Period A Placebo Adalimumab (N =398) (N = 814) n (%) n (%) Upper Respiratory Tract Infection 14 (3.5) 59(7.2) Nasopharyngitis 26 (6.5) 45 (5.3) Includes safety data up to 70days after last dose for patients not continuing into period B.

In conclusion, treatment with adalimumab 40 mg eow is efficacious forpatients with moderate to severe psoriasis. Efficacy is sustained duringopen-label adalimumab treatment. Discontinuation of adalimumab isassociated with loss of adequate response Percentages of serious AEs,serious infectious AEs, and malignancies were comparable betweenplacebo- and adalimumab-treated patients during Period A. Rates ofserious AEs, serious infectious AEs, and malignancies were low over the52-week duration of the study.

Example 12: Efficacy and Safety of Adalimumab Treatment in Patients withModerate to Severe Psoriasis Patients: A Double-Blind, RandomizedClinical Trial

It is necessary to assess the efficacy and safety of adalimumab therapyfor patients with moderate to severe plaque psoriasis and evaluate theduration of treatment response after withdrawal from or dosage reductionof adalimumab therapy. Accordingly, the objective of this clinical trialwas to investigate the time to relapse after either withdrawal ofadalimumab or continued adalimumab therapy (but at a dosage lower [40 mgcow] than initially used) in patients with moderate to severe chronicplaque psoriasis who had achieved a Psoriasis Area and Severity Index(PASI) response of at least 50% after 12 weeks of open-label 40-mgweekly therapy.

In this multicenter, randomized, double-blind, placebo-controlled study,patients with moderate to severe plaque psoriasis received 12-week,open-label therapy with subcutaneous adalimumab, consisting of 80 mg ofadalimumab at Weeks 0 and 1, followed by 40 mg weekly Weeks 2-11. AtWeek 12, patients who had an improvement in Psoriasis Area and SeverityIndex (PASI) score of ≧50% were randomized to blinded therapy andreceived either adalimumab 40 mg every other week (eow) or placebo foran additional 12 weeks. A diagram of the study design is shown in FIG.8. During the double-blind period, 33.8% (23/68) of placebo patientsdiscontinued early, vs. 25% (17/68) of adalimumab 40 mg eow patients(FIG. 9). This trial also featured a 52-week, follow-up period, duringwhich no patients received injections in order to collect additionalinformation regarding treatment-free relapse.

Baseline data were similar among randomization groups. Baseline todemographics, disease severity characteristics, and recent history ofsystemic therapies were similar across the treatment groups. Table 68shows the baseline demographics and clinical characteristics.

TABLE 68 Baseline Demographics and Clinical Characteristics Randomizedpatients All patients (Week 12) (baseline) Placebo AdalimumabCharacteristic (N = 148) (N = 68) 40 mg eow (N = 68) Age, years 44(18-69)  45 (19-69)  43 (18-64) Male, % 63 66 56 Caucasian, % 94 96 91Body weight, kg  92 (47-155)  90 (55-155)  90 (47-150) Duration ofpsoriasis, years 20 (2-52) 20 (2-45) 21 (2-52) BSA affected, % 25 (5-99)25 (5-91) 25 (5-99) PASI score 16.4 (8-46)   16.3 (8-39)   16.4 (8-46)  History of psoriatic arthritis, % 29.0% 26.5% 35.3% PGA, % Severepsoriasis 13 16 10 Moderate to severe psoriasis 40 41 38 Valuesrepresent means and ranges unless otherwise specified. BSA = bodysurface area; PASI = Psoriasis Area and Severity Index; PGA =Physician's Global Assessment; eow = every other week.

During open-label treatment with adalimumab 40 mg weekly, most patientsexperienced clinically significant improvements in their psoriasis(Table 69. Clinical response was rapid, with a PASI 50 response rate of28% at Week 2 of therapy. Ultimately, a PASI 50 response rate wasobserved in the vast majority of patients, with 92% (136/148) reachingPASI 50 at Week 12. In addition, PASI 75 and PASI 90 responses wereachieved by 76.4% (113/148) and 47.3% (70/148) of patients,respectively. The percentage of patients who achieved a PGA “Clear” or“Minimal” was 66% (98/148) at Week 12. Patients with a recent history oftreatment with biologic agents (within the past year), including TNFantagonists, had PASI 50 response rates similar to those ofbiologic-naive patients. To this point, 12/14 patients exposed toetanercept, 4/4 patients exposed to infliximab, 6/6 exposed toalefacept, and 14/15 exposed to efalizumab achieved >PASI 50 responsesand were randomized to placebo or adalimumab eow at Week 12.

TABLE 69 PASI Response During Open-Label Therapy, Weeks 0-12* WeekPatients (%) PASI50 4 59 8 84 12 92 PASI75 4 26 8 55 12 30 PASI90 4 9 830 12 47 *Patients with missing scores swere considered non-responders.

During the double-blind, placebo-controlled period (Weeks 12-24), themajority of patients in both groups sustained >PASI 50 scores vs.baseline. The point estimate of the hazard ratio of the risk of relapsefor patients continuing on adalimumab was 0.7 (95% CI of 0.37-1.34),with a hazard ratio below 1 signifying lower risk of relapse than wouldbe observed in the overall psoriasis population.

At Week 24, greater percentages of patients who had been randomized toadalimumab 40 mg eow sustained efficacy response, as assessed by severalefficacy measures, compared with patients who had been randomized toadalimumab withdrawal (Table 70). A greater percentage of patientsrandomized to adalimumab 40 mg eow (54.4% [37/68]) achieved PGA “Clear”or “Minimal” at Week 24 vs. patients who were withdrawn from adalimumab(39.7% [27/68]) (p=0.069). For patients who achieved >PASI 75 at Week12, the relapse rate (loss of PASI 50 response relative to baseline) atWeek 24 was 17.2% for patients randomized to adalimumab eow and 23.6%for patients randomized to placebo.

TABLE 70 Percentages of patients achieving at least 75% and 90%Improvements in PASI at Week 24* Patients (%) Placebo PASI50 66 PASI7549 PASI90 28 Adalimumab PASI50 78 40 mg eow PASI75  68** PASI90  47***Patients with missing scores were considered non-responders. **p < 0.05vs. placebo

Adalimumab therapy was generally well-tolerated (Table 71). Of the 148patients who received at least one dose of adalimumab, three withdrewbecause of an adverse event. The most frequently reported adverse eventswere nasopharyngitis and upper respiratory infection. The incidences ofspecific adverse events during Weeks 12-24 to were similar between theplacebo and adalimumab eow groups, with the exception of reports ofarthralgias in the adalimumab group (7.4%), which were characterized asmild to moderate. Across the open-label and placebo-controlled periodsof the trial, adverse events were most often mild or moderate andtypically deemed unrelated or probably unrelated to treatment by theinvestigators.

TABLE 71 Adverse events by treatment group during the open-label (Weeks0-11) and double-blind (Weeks 12-24) treatment periods Open-label periodDouble-blind period 40 mg weekly Placebo 40 mg eow Event, n (%) (N =148) (N = 68) (N = 68) Any AE 105 (70.9)  36 (52.9) 46 (67.6) Any SAE 2(1.4) 0 2 (2.9) Any infectious SAE 1 (0.7) 0 2 (2.9) Any AEs leading to1 (0.7) 0 2 (2.9) discontinuation Adverse Events* Upper respiratory 9(6.1) 6 (8.8) 10 (14.7) tract infection Injection site reaction 17(11.5) 1 (1.5) 4 (5.9) Nasopharyngitis 11 (7.4)   7 (10.3) 3 (4.4)Headache 11 (7.4)  0 1 (1.5) Arthralgia 4 (2.7) 0 5 (7.4) All data arefor the types of adverse events that occurred in ≧5% of patients in anygroup. AE = adverse event; eow = every other week; SAE = serious adverseevent; eow = every other week.

Four patients experienced serious adverse events during the 24-weektrial. The two serious adverse events in the open-label period werecellulitis due to insect bite and limb pain, which were attributed bythe investigator to fissures in the psoriatic plaques of the lowerextremities. The two serious adverse events in the placebo-controlledperiod were diverticulitis and post-operative wound infection afterMohs' surgery for a basal cell carcinoma of the left hand with flaprepair (both events in the adalimumab 40 eow group).

Three patients discontinued prematurely primarily because of an adverseevent: one during the open-label period and two after randomization toadalimumab 40 mg eow. During the initial open-label period, one patientwho experienced cellulitis subsequently developed acute renal failure,which the investigator ascribed to antibiotic treatment and deemed notrelated to study drug. Another patient in the open-label perioddeveloped pneumonia. This event was deemed possibly related to studydrug. However, the patient's primary reason for discontinuation waswithdrawal of consent. During the second, blinded period of the trial, apatient experienced a post-operative wound infection and subsequentlydeveloped a basal cell carcinoma and squamous cell carcinoma of theskin. Both of these events were deemed mild and considered possiblyrelated to study drug by the investigator.

No patients developed tuberculosis or other opportunistic infections,lymphoma, melanoma, malignancies other than non-melanoma skin cancers,demyelinating disorders, lupus-like syndromes, or congestive heartfailure. One patient in the adalimumab weekly/placebo group developed aherpes simplex infection, which was deemed a flare of a pre-existingherpes infection and was considered probably not related to studymedication by the investigator. The patient who developed threenon-melanoma skin cancers during the study previously had akeratoacanthoma excised 2 years earlier.

Three patients were classified by investigators as “rebounders.” Onepatient had a baseline PASI score of 19.5, which increased to 27.3 byWeek 4 of the open-label period. However, the patient did notdiscontinue, and, upon continued therapy, achieved a PASI score of 6.9at Week 12. Another patient had a baseline PASI score of 17.1 and wasassessed as having a treatment-emergent AE of “psoriasis aggravated”during the treatment-free follow-up period, at which time the patient'sPASI score was 1.6. A third patient had a baseline PASI of 31.8 and wasassessed as having a treatment-emergent AE of “worsening of psoriasis”during the treatment-free follow-up period, at which time this patient'sPASI score was 15.5. None of the three patients met the study'spre-specified definition of rebound (ie, PASI score >125% of Week-0 PASIscore or new generalized pustular or erythrodermic psoriasis any timeafter Week 12 and within 90 days of last dose of study drug).

The majority of patients had no clinically significant laboratoryabnormalities or changes from baseline during the 24-week period. Nopatients discontinued because of laboratory abnormalities. No patientshad alanine aminotransferase (ALT) elevations greater than 2.5 times theupper limit of normal at Week 12. One patient in the to adalimumab eowgroup had an ALT elevation greater than 2.5 times the upper limit ofnormal (212.0 U/ml) at Week 24. At the 30-day follow-up visit, thepatient's ALT value was 125.0 U/ml. The patient was a self-reportedmoderate drinker.

In conclusion, weekly adalimumab therapy rapidly improved psoriasisduring an initial 12-week period. Improvement was sustained in most, butnot all patients, despite dosage reduction to every other week. Nopatients randomized to adalimumab withdrawal (placebo at Week 12)experienced rebound, and most maintained >PASI50 improvement, relativeto baseline, during the 3 months following adalimumab discontinuation.Overall, greater efficacy rates were observed for patients randomized toadalimumab 40 mg eow than for patients randomized to adalimumabwithdrawal.

Example 13: A Comparison of Quality of Life Improvement as Measured byEQ-5D with Clinical Response in Moderate to Severe Plaque PsoriasisPatients Treated with Adalimumab

The objective of this analysis was to assess the relationship betweenclinical efficacy and EQ-5D in moderate to severe plaque psoriasispatients treated with adalimumab for 12 weeks. Because moderate tosevere psoriasis impairs patient function, patient-reported outcomes(PROs) that measure this effect are important in determiningeffectiveness of treatment. Clinical trials of biologics in patientswith psoriasis have demonstrated significant improvements in PROs, aswell as in clinical endpoints. However, the sensitivity of EQ-5D toclinical change has not been established. Several PRO measures,including the EuroQoL 5D (EQ-5D), were included as secondary efficacyendpoints in a 12-week, Phase II, placebo-controlled trial of adalimumabfor the treatment of moderate to severe plaque psoriasis. The EQ-5D is avalidated measure of general health status.

In this randomized, double-blind, multi-center clinical trial (FIG. 1),patients were randomized to one of three treatment groups: 80 mgadalimumab at baseline (Week 0) and 40 mg at Week 1 followed by 40 mgevery other week (eow) starting at Week 3; 80 mg adalimumab at baseline(Week 0) and 80 mg at Week 1 followed by 40 mg weekly starting at Week2; or placebo administered weekly starting at baseline. Inclusioncriteria included a diagnosis of moderate to severe chronic plaquepsoriasis >1 year prior to entry, a psoriasis-affected body surface area(BSA) >5%, and no previous use of TNF-antagonist therapy. Therelationship between mean change in EQ-5D and clinical responses wasevaluated from baseline to Week 12. Table72 shows the baseline todemographics of the patients included in the study.

TABLE 72 Baseline Demographics Characteristic (n = 147) Age Mean (SD)44.2 (12.7)   Gender Female n (%) 48 (32.7%) Male n (%) 99 (67.3%) RaceWhite n (%) 133 (90.5%)  Black n (%) 4 (2.7%) Asian n (%) 5 (3.4%) Othern (%) 5 (3.4%)

PROs included the EQ-5D. The EQ-5D is a 6-item instrument validated tomeasure general health status. The EQ-5D consists of two measures: theEQ-5D Index, which consists of five items to assess level of function(mobility, self-care, usual activities, pain/discomfort, andanxiety/depression), each rated on a 3-point scale ranging from “noproblem” to “extreme problem” to “unable to do”; and the EQ-5D VAS,which is a visual analog scale scored from 0-100, with 100 representing“best imaginable health” and 0 representing “worst imaginable health.”

There were two primary clinical outcome measures in this clinical trialof adalimumab: Psoriasis Area and Severity Index (PASI), and Physician'sGlobal Assessment (PGA). PASI improvement is frequently used as anendpoint in psoriasis clinical trials. PASI improvement ≧75% at Week 12was the primary efficacy outcome measure for this trial. PASI is acomposite index indicating severity for three main signs of psoriaticplaques (erythema, scaling, and thickness), weighted by the amount ofcoverage of these plaques in four main body areas (i.e., head, trunk,upper extremities, and lower extremities). PASI scores range from 0-72,with higher scores indicating greater severity. PASI scores wereassessed at screening; baseline; Week 1, Week 2, Week 4, Week 8, andWeek 12/early termination; and follow-up.

The PGA is a 7-point scale used to measure disease severity from aphysician's evaluation. The categories for the 7-point scale include:Severe: very marked plaque elevation, scaling, and/or erythema; Moderateto severe: marked plaque elevation, scaling, and/or erythema; Moderate:moderate plaque elevation, scaling, and/or erythema; Mild to moderate:intermediate between moderate and mild; Mild: slight plaque elevation,scaling, and/or erythema; Almost clear: intermediate between mild andclear; and Clear: no signs of psoriasis (post-inflammatoryhypopigmentation or to hyperpigmentation could be present). The scoringranges are from 1 (Clear) to 7

(Severe). PGA was assessed at screening, baseline, Week 1, Week 2, Week4, Week 8, Week 12/early termination, and follow-up. The sameinvestigator performed this assessment for each patient throughout thestudy.

Data were available at the end of trial for 140 of the 147 patientsenrolled. Mean values at baseline and mean values/change in mean valuesafter 12 weeks for the EQ-5D index score and VAS score, as well as forPASI and PGA, are shown in Table 73. EQ-5D demonstrated significantresponsiveness to changes in clinical efficacy. The correlationcoefficient between EQ-5D and PASI response was 0.57 (p<0.001), andbetween EQ-5D and PGA was 0.44 (p<0.001). Mean change in EQ-5D was 15.69in patients with >PASI 75 response vs. 1.92 points in non-responders(<PASI 50 response) (p<0.0001). Table 74 below shows the correlationsbetween changes in EQ-5D with PASI and PGA. All correlations in Table 74are significant (p<0.001).

TABLE 73 Mean (SD) EQ-5D and Clinical Measures at Baseline and Week 12Baseline Week 12 Change² (N = 147) (N = 140) (N = 140) EQ-5D:VAS-Overall 72.25 (20.67) 81.22 (17.26)  9.35 (20.71) Health EQ-5D:Total Index 0.66 (0.28) 0.82 (0.23)  0.16 (0.29) Score Psoriasis Areaand 15.7 (7.3)  6.8 (7.8) −8.9 (8.4) Severity Index (PASI) Physician'sGlobal 5.5 (0.8) 3.4 (1.7) −2.1 (1.9) Assessment¹ (PGA) ¹Scored suchthat 1 = “Clear” to 7 = “Severe.” ²Calculated only for patients withboth baseline and Week-12 scores. Numbers in parentheses are standarddeviations (SD).

TABLE 74 Correlation Between Changes in EQ-5D with PASI and PGA PASI PGAEQ-5D: VAS Overall Health −0.43 −0.38 EQ-5D: Total Index Score −0.57−0.44 PASI 1.00 0.75

The mean change in EQ-5D index scores was 0.25 (0.30) for patientswith >PASI 75 response versus 0.04 (0.29) for non-responders (<PASI 50response) (p=0.0006), as shown in Table 75.

TABLE 75 Mean (SD) EQ-5D Change Score Corresponding to Levels of PASIImprovement PASI Improvement Change in <25% 25%-49% 50%-74% ≧75% OverallEQ-5D (n = 31) (n = 22) (n = 21) (n = 66) F-Value Index Score −0.01(0.26)  0.10 (0.24)  0.20 (0.21)  0.25 (0.30) 7.1** VAS-General 0.58(24.31) 3.82 (22.07) 8.43 (11.24) 15.69 (18.69) 4.8*  Health Negativechange scores indicate improvement; p-values are: *<0.01 and **<0.001.Post-hoc tests indicate that the PASI <25% group differed significantlyfrom the PASI >75% group. Numbers in parentheses are standard deviations(SD).

Patients in both adalimumab treatment arms demonstrated statisticallysignificant improvement versus placebo in EQ-5D, in PASI 75 responserate, and in percentage of patients with PGA “clear” or “almost clear”from baseline to Week 12 (see Table 76 through Table 79).

TABLE 76 Mean Change in EQ-5D Index at Week 12 Adalimumab AdalimumabPlacebo 40 mg eow 40 mg weekly Change from 0.014 0.212 0.198 Baseline

TABLE 77 Mean Change in EQ-5D VAS at Week 12 Adalimumab AdalimumabPlacebo 40 mg eow 40 mg weekly Change from 0.6 18 10.9 Baseline

TABLE 78 Percentages of Patients with PGA “Clear” or “Almost Clear” atWeek 12 Adalimumab Adalimumab Placebo 40 mg eow 40 mg weekly % ofPatients 2 51 81

TABLE 79 Percentages of Patients with > PASI 75 Response at Week 12Adalimumab Adalimumab Placebo 40 mg eow 40 mg weekly % of Patients 4 5380

Overall, the EQ-5D VAS and index scores were highly responsive toclinical improvement in patients with moderate to severe plaquepsoriasis who received adalimumab. The level of agreement shown suggeststhat adalimumab may be highly efficacious in improving both healthstatus and clinical efficacy in patients with moderate to severe plaquepsoriasis.

Example 14: Long-Term Safety and Efficacy of Adalimumab in the Treatmentof Moderate to Severe Chronic Plaque Psoriasis

Psoriasis is a chronic inflammatory proliferative disease of the skinthat affects 1-3% of the general population. Conventional treatments ofpsoriasis such as NSAIDs and DMARDs fail to achieve adequate efficacy.Newer biologics have been developed that focus on the immunopathogenicpathway of the disease.

A 12 week, double-blind placebo controlled trial, with a 48 weekextension, was performed to evaluate the long-term safety and efficacyof adalimumab in the treatment of moderate to severe chronic plaquepsoriasis. The criteria for inclusion in this study were as follows:patients were at least 18 years of age; patients had moderate to severechronic plaque psoriasis for at least one year; and patients had a BSAof at least 5%. Patients were excluded if they had prior TNF-antagonisttherapy, and/or if they had discontinued other systemic psoriasistherapies. The study design is shown in FIGS. 1 and 5

The baseline demographics and clinical characteristics of the patientpopulation included in this study are shown below in Table 2.

TABLE 80 Baseline Demographics and Clinical Characteristics* AdalimumabAdalimumab 40 mg eow 40 mg weekly Placebo (n = 52) (n = 45) (n = 50)Age, years (range) 43 (20-70) 46 (20-71) 44 (24-86) Duration of Ps,years 19.1 (1.0-39.8) 20.5 (1.3-57.9) 18.4 (1.7-47.7) (range) % Male 6571 66 % Caucasian 92 89 90 Body weight, kg 94 (50-147) 93 (63-159) 99(42-149) (range) % BSA (range) 27.7 (7-75) 29.2 (6-58) 24.6 (5-83)Psoriasis Area and 16.0 (5.5-40.4) 16.7 (5.4-39.0) 14.5 (2.3-42.4)Severity Index (PASI) Score (range) % with PsA 31 33 24 *Mean valuesexcept percentages Langely, R., et al., J. Am. Acad. Dermatol. 2005;52(3 Suppl): 2.

Overall, patients with moderate to severe psoriasis treated withadalimumab achieved sustained efficacy through 60 weeks of treatment(see Table 80). At week 12, placebo patients received an 80-mg loadingdose, then 40 mg every other week. Patients with missing PASI scoreswere considered non-responders. Patients with less than PASI 50 responseon or after week 24 received OL weekly adalimumab rescue therapy.Patients who receive the rescue therapy were considered non-respondersin this analysis.

TABLE 80 Psoriasis Efficacy is Sustained Through 60 Weeks of AdalimumabTherapy Week 12 Week 24 Week 36 Week 60 Percentage of 0 11 19 19patients treated with placebo/adalimumab 40 mg eow who achieved PASI 100Percentage of 11* 13 22 16 patients treated with adalimumab 40 mg eowwho achieved PASI 100 Percentage of 26* 24 36 26 patients treated withadalimumab 40 mg weekly who achieved PASI 100 *p < 0.001 versus placebo.N = 148 (modified ITT, N = 147) at week 12. N = 142 at weeks 12 through60.

The PASI 90 results through week 60 are shown below in Table 18. At week12, placebo patients received an 80-mg loading dose and then a 40 mgdose every other week. Patients with less than PASI 50 response on orafter week 24 received OL weekly adalimumab rescue therapy. Patientsreceiving rescue therapy were considered non-responders in thisanalysis.

TABLE 81 PASI 90 Results through Week 60 Week 12 Week 24 Week 36 Week 60N = 147 N = 142 N = 142 N = 142 Percentage of patients 0 32 43 40treated with placebo/adalimumab 40 mg eow who achieved PASI 90Percentage of patients 24* 42 49 33 treated with adalimumab 40 mg eowwho achieved PASI 90 Percentage of patients 48* 62 58 48 treated withadalimumab 40 mg weekly who achieved PASI 90 *p < 0.001 versus placebo.Modified ITT, NRI

In the adalimumab 40 mg every other week treatment group, 58% ofpatients achieved a PASI 75 response at week 60 (see Table 82 below). Atweek 12, placebo patients received an 80-mg loading dose and then a 40mg dose every other week. Patients with less than PASI 50 response on orafter week 24 received OL weekly adalimumab rescue therapy. Patientsreceiving rescue therapy were considered non-to responders in thisanalysis.

TABLE 82 PASI 75 Results through Week 60 Week 12 Week 24 Week 36 Week 60N = 147 N = 142 N = 142 N = 142 Percentage of patients 4 55 62 45treated with placebo/adalimumab 40 mg eow who achieved PASI 75Percentage of patients 53* 64 64 58 treated with adalimumab 40 mg eowwho achieved PASI 75 Percentage of patients 80* 72 68 64 treated withadalimumab 40 mg weekly who achieved PASI 75 *p < 0.001 versusplacebo/adalimumab 40 mg eow group Modified ITT, NRI

The PASI 50/75/90 results at weeks 12 and 60 are shown in Table 83. Atweek 12, the group of patients receiving placebo began an 80 mg loadingdose, followed by 40 mg every other week. Patients for whom adalimumabdosages were escalated were considered non-responders from time of doseescalation forward.

TABLE 83 PASI 50/75/90 at Weeks 12 and 60 Week 12 Week 60 (n = 147) (n =142) PASI 50 PASI 75 PASI 90 PASI 50 PASI 75 PASI 90 (% patients) (%patients) (% patients) (% patients) (% patients) (% patients) placebo/17 4 0 64 45 40 adalimumab 40 mg eow adalimumab 76 53 24 67 58 33 40 mgeow adalimumab 88 80 48 66 64 48 40 mg weekly Modified ITT, NRI

The percentage of patients included in this study who achieved a PGA of“clear” or “almost clear” is shown below in Table 84. At week 12,placebo patients received an 80 mg loading dose, and then received 40 mgevery other week. Patients with less than a PASI 50 response on or afterweek 24 received OL weekly adalimumab rescue therapy. Patients receivingrescue therapy were considered non-responders in this analysis.

TABLE 84 Percentage of Patients Achieving PGA “Clear” or “Almost Clear”Week 12 Week 24 Week 36 Week 60 N = 147 N = 142 N = 142 N = 142placebo/adalimumab 2 45 51 45 40 mg eow (% patients) adalimumab 40 mg49* 64 60 44 eow (% patients) adalimumab 40 mg 76* 72 68 52 weekly (%patients) *p < 0.001 versus placebo/adalimumab 40 mg eow group ModifiedITT, NRI

The mean percentage PASI improvement through week 60 is shown in FIG.10. At week 12, placebo patients received an 80-mg loading dose ofadalimumab, and then a 40 mg dose every other week. The PASI score wascarried forward when the patient began rescue therapy. As can be seen inFIG. 10, at week 60, there was an 84% overall PSAI improvement inpatients receiving a 40mg weekly dose of adalimumab, and a 69% PASIimprovement in patients receiving either a 40 mg every other week dosageof placebo/adalimumab, or 40 mg of adalimumab alone, on a weekly basis.The PASI response after dose escalation from every other week to weeklydosing is shown in Table 85.

TABLE 85 PASI Response After Dose Escalation Efficacy at Weeks 24-60Efficacy at Week 60 (n = 22) (n = 22) PASI 50 PASI 75 PASI 90 PASI 50PASI 75 PASI 90 (% (% (% (% (% (% patients) patients) patients)patients) patients) patients) 55 23 5 36 18 0The study described herein also indicated that a dose escalationimproves the outcome in a subset of patients. For example, 15% (two outof thirteen patients in the treatment arm that received a doseescalation) of patients in the original placebo/adalimumab 40 mg everyother week treatment arm had a PASI ≧75 at week 60. In the originaladalimumab 40 mg every other week treatment arm, 22% (two out of ninepatients) of patients receiving a dose escalation had a PASI ≧75 at week60. However, few patients needed dose escalation to achieve PASI 75 atweek 60 (see Table 86 below).

TABLE 86 Patients Eligible for Dose Escalation Placebo/AdalimumabAdalimumab Patients Eligible for Dose 40 mg eow 40 mg eow Escalation (n= 13) (n = 9) Week 24 5 5 Week 28 2 1 Week 32 2 0 Week 44 1 1 Week 52 30 Week 60 0 2 PASI 75 Response at Week 60 15% (2/13) 22% (2/9)

The types and rates of adverse events recorded in this study weresimilar to those previously reported in adalimumab rheumatoid arthritisand psoriatic arthritis trials. Table 87 shows the number of patientswho withdrew from the study, and the reasons for the withdrawal. Thenumber of adverse events by treatment period is shown in Table 88.

TABLE 87 Patient Disposition Integrated Data Set Placebo-ControlledPeriod Week 0-60 Week 0-12 Placebo/ Adalimumab Adalimumab AdalimumabAdalimumab Adalimumab Placebo 40 mg eow 40 mg weekly 40 mg eow 40 mg eow40 mg weekly (N = 52) (N = 45) (N = 50) (N = 52) (N = 45) (N = 50)Withdrawals 2 2 3 14 10 17 Adverse 1 2 2 2 4 8 events Lack of 1 0 0 6 64 Efficacy Withdrew 0 0 0 2 0 1 Consent Abnormal 0 0 1 0 0 1 lab valueOther 0 0 0 1 0 3 Did not Enter N/A N/A N/A 3 0 0 Study 1.2

TABLE 88 Adverse Events by Treatment Period Weeks 12-60 Weeks 0-12Placebo/Adalimumab Adalimumab 40 mg eow + Adalimumab Adalimumab 40 mgAdalimumab 40 mg 40 mg Placebo 40 mg eow weekly eow weekly Event, n (%)(n = 52) (n = 45) (n = 50) (n = 92) (n = 50) Any Adverse 35 (67.3) 28(62.2) 39 (78.0) 72 (78.3) 39 (78.0)  Event Serious Adverse 0 (0.0) 1(2.2  4 (8.0) 2 (2.2) 7 (14.0) Events Adverse Events 1 (1.9) 2 (4.4) 3(6.0) 3 (3.3) 5 (10.0) Leading to Withdrawal

Table 89 shows the most common adverse events that occurred in patientsbetween weeks 12 and 60.

TABLE 89 Common Adverse Events, Week 12-60 Placebo/Adalimumab 40 mgeow + Adalimumab Adalimumab 40 mg eow 40 mg weekly Event, n (%) (n = 92)(n = 50) Nasopharyngitis 13 (14.1) 6 (12.0) Upper Respiratory Infection,9 (9.8) 7 (14.0) Not otherwise specified Upper Respiratory Infection, 4(4.3) 3 (6.0) Viral not otherwise specified Muscle strain 1 (1.1) 4(8.0) Blood creatine phosphokinase 5 (5.4) 2 (4.0) increased Bloodtriglycerides increased 7 (7.6) 2 (4.0) Back pain 4 (4.3) 4 (8.0) Skinpapilloma 3 (3.3) 5 (10.0) Headache 3 (3.3) 6 (12.0) Urticaria 0 (0.0) 3(6.0)

Some serious adverse events that occurred during weeks 0-12 included:squamous cell carcinoma of the neck (in an ex-smoker, prior to studyentry); breast cancer on routine mammogram (5 weeks after entry);migraine; cerebrovascular accident reported by patient after last dose;and bronchitis. Some of the serious adverse events that occurred throughweeks 12-60 included: malignant melanoma (discovered under plaque thatcleared with adalimumab treatment); accidental fall with soft tissueinjury; osteoarthritis; kidney stones; stomach adenocarcinoma (historyof peptic ulcer disease); palpitations; coronary artery disease;malignant melanoma; and cerebrovascular to accident.

Example 15 Psoriasis Patients Treated Continuously with Adalimumab:Efficacy and Safety Results from Month 12 to 18

Objective: Adalimumab is a fully human, IgG₁ monoclonal antibodyspecific for tumor necrosis factor, a pivotal cytokine in thepathogenesis of psoriasis. This analysis was designed to determine thelong-term (up to 18 months) efficacy and safety of adalimumab inpatients with moderate to severe psoriasis.

Methods: REVEAL (Randomized Controlled EValuation of Adalimumab EveryOther Week Dosing in Moderate to Severe Psoriasis TriAL) was a 52 week,randomized, double-blind, placebo-controlled, Phase III clinical trialof adalimumab in 1,212 patients for the treatment of moderate to severechronic plaque psoriasis. Patients who completed REVEAL couldsubsequently enroll in an open-label extension (OLE), during whichcontinuous adalimumab therapy was administered. The experience duringthe first 6 months of OLE for the subset of patients who had receivedcontinuous adalimumab for 12 months in REVEAL was summarized based oninterim analyses conducted in May 2007. PASI responses were analyzedrelative to the baseline of REVEAL for the intention-to-treatpopulation, defined as patients who received continuous adalimumabdosing in the 52-week REVEAL, completed REVEAL, and received ≧1 dose ofadalimumab in OLE.

Main inclusion criteria for REVEAL were: clinical diagnosis of psoriasisfor ≧6 months; affected body surface area (BSA) >10%; PASI ≧12; and aPhysician's Global Assessment (PGA) of at least “Moderate”. Mainexclusion criteria was the previous use of systemic anti-TNF therapy.The study measured PASI 75, 90 and 100 response rates at weeks 0, 12,and 24 of the OLE period. PGA scores were assessed at weeks 0, 12 and to24 of the OLE period. Laboratory parameters and adverse events were alsorecorded.

The REVEAL study had two independent primary endpoints. The firstendpoint was the proportion of patients achieving 75 percent improvementin skin clearance after 16 weeks. The second endpoint was the proportionof patients who lost adequate response through week 52 after stoppingtreatment with HUMIRA at week 33. Signs of psoriasis were evaluatedusing the Psoriasis Area and Severity Index (PASI), among othermeasures. Patients receiving adalimumab who achieved at least a PASI 75response at week 16 continued to receive adalimumab on an open-labelbasis. At week 33, the 490 patients who maintained PASI 75 wererandomized to receive placebo or continue receiving adalimumab. At week52, the start of the OLE period, patients randomized at week 33, as wellas patients originally in the placebo group at week 0, were able toenter the OLE period. Patients in the OLE period received 40 mgadalimumab EOW.

Results: PASI 75 response scores were measures at the end of weeks 4, 8,12, 16 and 24 during the double-blind phase of the study. PASI 75, 90and 100 response rates were also measured at weeks 0, 12 and 24 of theOLE (weeks 52, 64 and 76 after the start of REVEAL). PGA scores wereassessed at the same timepoints during OLE. Results are shown below inTables 90-92.

TABLE 90 PASI 75 Response: Week 0 to 24 Placebo† Adalimumab‡ Week 4 1.3%18.9% * Week 8 3.0% 54.1% * Week 12 4.8% 67.7% * Week 16 6.5% 71.0% *Week 24  70.3% ** * p < 0.001 adalimumab vs placebo; †n = 398; ‡n = 814** Pooling of efficacy outcomes from Period B (wks. 16 to 33) and OLEITT: NRI

TABLE 91 PASI Response Rates During the First 24 Weeks of OLE PASI 75PASI 90 PASI 100 Week 0 85% 84% 87% Week 12 59% 60% 63% Week 24 35% 33%34% n = 233; ITT: Last observation carried forward (LOCF).

TABLE 92 PGA Scores of “Clear” or “Minimal” During the First 24 Weeks ofthe OLE PGA “Clear” or “Minimal” Week 0 70% Week 12 71% Week 24 74% n =233; ITT: LOCF

TABLE 93 Adverse Events During the First 24 Weeks of OLE Adverse Events(AEs) Patients (%) Any AE 47 AEs leading to withdrawal 1 Infectious AEs18 Serious AE* 3 Serious infectious AE 1 Malignancy† 1 Lymphoma 0Non-melanoma skin cancer 0 AEs occurring ≧5% of patients Nasopharyngitis5 *Serious AEs included a bile duct stone, coronary artery disease in apatient with a history of coronary artery bypass graft, myocardialinfarction (MI) in a patient with a history of 2 previous MIs, renalcell carcinoma, gastroenteritis, and staphylococcal infection. †Renalcell carcinoma and prostate cancer.

A total of 233 patients were included in the intention-to-treatpopulation. Their PASI 75/90/100 response rates were 85%/59%/35% after12 months of continuous adalimumab dosing, and 87%/63%/34% after 18months. Six patients (2.6%) experienced serious adverse events, and 2patients (0.9%) reported serious infections (between Months 12-18). PGAscores of “clear” or “minimal were reported for 74% of patients.

Conclusion: Patients who had received adalimumab for 12 monthsexperienced sustained improvement when continued through 18 months.Adalimumab was safe and well-tolerated for up to 18 months of treatment.Long-term adalimumab treatment of patients with moderate to severepsoriasis was associated with sustained and substantial degrees ofimprovement and a low risk of serious infections, which suggests afavorable benefit/risk balance.

Example 16. Methotrexate-treated Psoriasis Patients Transitioning toAdalimumab: Efficacy and Safety Outcomes

Objective: Adalimumab is a fully human, IgG₁ monoclonal antibody thatinhibits TNF, a pivotal cytokine in the pathogenesis of psoriasis. Thisanalysis was conducted to determine the efficacy and safety oftransitioning methotrexate-treated psoriasis patients to adalimumab.

Methods: CHAMPION was a 16-week, Phase III, active- andplacebo-controlled trial in which patients with moderate to severechronic plaque psoriasis were randomized to receive placebo,methotrexate, or adalimumab. Patients who completed CHAMPION couldsubsequently enroll in an open-label extension (OLE) study, during whichpatients received adalimumab 40 mg every other week. Patient experienceassociated with transitioning from methotrexate to adalimumab wassummarized based on interim analyses conducted in May 2007. PASIresponses were analyzed relative to baseline of CHAMPION for theintention-to-treat population, defined as patients who were randomizedto methotrexate in the 16-week CHAMPION, completed CHAMPION, andreceived ≧1 dose of adalimumab in the OLE.

Results: At week 16 of CHAMPION, PASI response rates were evaluated fromplacebo, methotrexate and adalimumab patients. Results are shown inTable 94.

TABLE 94 PASI Response Rates at Week 16 of CHAMPION Placebo (N = 53) MTX(N = 110) ADA (N = 108) PASI 50 30.2% 61.8% 88.0% *† PASI 75 18.9% 35.5%79.6% *† PASI 90 11.3% 13.6% 51.9% *† PASI 100 1.9% 7.3% 16.7% ‡§ * p <0.001 vs. placebo; † p < 0.001 vs. MTX; ‡ p < 0.01 vs. placebo; § p <0.05 vs. MTX. Analysis: ITT, nonresponder imputation (NRI). ITTpopulation defined as population randomized in CHAMPION. Saurat J H, etal. Br J Dermatol. 2007; DOI: 10.1111/j.1365-2133.2007.08315.x.a.

The intention-to-treat population comprised 95 patients. These patientsreceived a mean methotrexate dose of 19.1 mg in the penultimate week ofCHAMPION. Their PASI 75/90/100 response rates were 28%/14%/5% prior tostarting adalimumab, 75%/47%/18% after 12 weeks of adalimumab therapyand 73%/53%/32% after 24 to weeks of adalimumab therapy. No cases ofrebound were observed, and no patients experienced serious infectionsduring the first 24 weeks of the OLE. Adverse events are presented inTable 95.

TABLE 95 Adverse Events through Week 24 of the OLE (N = 95) AdverseEvents (AE) Percentage of Patients Any AE 47 AEs leading to withdrawal 1Infectious AEs 15 Serious AE* 5 Serious infectious AE 0 Reboundpsoriasis 0 Any malignancy 0 AEs occurring ≧5% of patientsNasopharyngitis 6 Injection-site reaction 5 *Serious AEs during the OLEincluded pneumothorax, neuralgia, avascular necrosis of hip, spontaneousabortion, and motorbike accident.

Conclusion: The transition of patients with psoriasis from methotrexateto adalimumab was safe and well-tolerated (no rebound psoriasis observedwhen adalimumab was started 1 week after MTX was discontinued), with lowrisk of serious infections. Adalimumab therapy led to substantial skinimprovements in these transitioning patients and was found to be moreefficacious than MTX for treatment of moderate to severe chronic plaquepsoriasis.

Example 17 Health-Related Quality of Life (HRQOL) and Work ProductivityOutcomes for Psoriasis Patients in Europe

Background: Psoriasis (Ps) dramatically affects patients' HRQOL anddaily functioning. Ps often leads to work impairment in 2 forms:absenteeism and presenteeism (reduced productivity while at work).

Objectives: With data on patient-reported outcomes, this studyinvestigated the extent to which Ps impairs patients' HRQOL, or leads toabsence from work, reduced productivity while at work, and decreases indaily activities.

Methods: The study consisted of respondents to a 2007 EU National Healthand Wellness Survey (NHWS), an annual cross-sectional survey ofrepresentative samples of adults (≧18 years) from 5 countries (France,Germany, Italy, Spain, UK). The Internet survey was completed by 53,524respondents in June 2007. We assumed self-reports of a diagnosis of Pswere bona fide. All respondents completed a self-administeredquestionnaire, which included the Short Form 12 (SF-12) and WorkProductivity and Activity Impairment (WPAI) questionnaire. Results werestratified by disease severity based on BSA affected (mild, <2% BSA;moderate, 2-10%; severe, ≧10%) and compared with the non-Ps population.Bivariate analyses compared subgroups. Statistical testing employedZ-test in Quantum for percentages and t-tests for means.

Results: 2,288 respondents reported being diagnosed with Ps by aphysician. Of these, 598 reported moderate (n=484) or severe (n=114)disease. SF-12 results demonstrated poor quality of life, via both thePhysical and Mental Component Summary scores, especially for patientswith moderate and severe Ps. Overall, moderate and severe Ps patientsreported significantly lower mental and physical health status than mildand non-Ps sufferers (PCS: 48.51, 46.62, 45.18, and 43.09; MCS: 46.86,45.43, 42.74, and 41.12, for non-Ps, mild, moderate and severe Ps,respectively, p<0.05). For employed patients with severe Ps, a mean4-hour absence from work per week was reported, vs. 2 hours per week formild and non-Ps sufferers (p<0.05). For patients with moderate Ps, amean of 3 hours' absence from work per week was reported, which wasgreater than the absence of non-Ps sufferers (p<0.05). If those withabsenteeism alone (19%) were considered, mean hours missed were 16/weekand 18/week for moderate and severe Ps patients, respectively. Moderateand severe Ps sufferers had greater work productivity and activityimpairment vs. mild or non-Ps sufferers (p<0.05). Severe Ps sufferershad 29% impairment in work productivity and 28% impairment in dailyactivities, while moderate Ps patients had 24% and 25% impairmentsrespectively. By comparison, mild Ps patients/non-Ps sufferer reportedlower reductions in work impairment (20%/17%) and daily activities(19%/17%).

Conclusions: Psoriasis has both physical and mental impacts, whichincrease with severity. Associated loss in work productivity and dailyactivities has considerable costs to society. Therapies that helppatients achieve mild disease or remission improve HRQOL and workproductivity outcomes.

Example 18 Effect of Adalimumab Treatment on C-Reactive Protein inPatients With Moderate to Severe Psoriasis

Background: C-reactive protein (CRP), a biomarker of systemicinflammation, is elevated in patients with psoriasis (Ps) and is apredictor of future cardiovascular risk. Recent studies havedemonstrated that patients with moderate to severe Ps are at increasedrisk for cardiovascular disease.

Objectives: To evaluate CRP concentrations in patients with moderate tosevere Ps before and after treatment with adalimumab.

Methods: REVEAL (Randomized Controlled Evaluation of Adalimumab EveryOther Week Dosing in Moderate to Severe Psoriasis Trial) was a 52-week(wk), double-blind, randomized, placebo-controlled, Phase III trial ofadalimumab in patients with moderate to severe chronic plaque Psconducted in the United States and Canada. During the first 16 weeks(Period A), patients were treated with adalimumab (80 mg at Wk 0, 40 mgevery other wk from Wk 1-15) or placebo. This post-hoc analysis ofREVEAL evaluated CRP concentrations in Ps patients at baseline and after16 wks of treatment with adalimumab or placebo. Changes in CRPconcentrations were also evaluated in subgroups with or withoutself-reported psoriatic arthritis (PsA) and with or without obesity (bybody mass index [BMW. The CRP assay had an upper limit of normal of 9.0mg/L. The lower limit of detection was 4.0 mg/L; results 4.0 wererecorded as 4.0 mg/L.

Results: Of 1,212 patients in REVEAL, 814 were randomized to adalimumaband 398 were randomized to placebo. At baseline, 28% of patients hadPsA, and the mean BMI was 31 kg/m² (obese). For patients in the Ps group(i.e., without self-reported PsA), the mean CRP concentrations atbaseline were 6.5 mg/L (range 4.0-70.8) for adalimumab-treated patientsand 6.4 mg/L (range 4.0-61.3) for placebo-treated patients; the meanchanges from baseline in CRP were −1.3 vs. 0.3 (p<0.01). Of thosepatients in the Ps group with an elevated CRP at baseline, 64.6% ofadalimumab patients (53 of 82) vs. 33.3% of PBO patients (13 of 39) hada normal CRP at Wk 16 (p=0.0017). For patients in the PsA group, themean CRP concentrations at baseline were 11.6 mg/L (range 4.0-206.0) foradalimumab-treated patients and 9.7 mg/L (range 4.0-106.0) forPBO-treated patients; the mean changes from baseline in CRP were −6.3vs. −1.9 (p<0.01). Of those patients in the PsA group with an elevatedCRP at baseline, 71.9% of adalimumab patients (41 of 57) vs. 42.9% ofplacebo patients (12 of 28) had a normal CRP at Week 16 (p=0.017). Ofpatients who were obese, 64.1% of adalimumab patients (59 of 92) and 36%of placebo patients (18 of 50) changed from an elevated CRPconcentration at baseline to a normal CRP at Week 16 (p=0.0016).

Conclusions: Among patients with moderate to severe Ps, CRPconcentrations were greater for those with PsA than with those with Psalone. Adalimumab treatment led to significant reductions in CRPconcentrations, regardless of the presence of PsA or obesity.

Example 19: Efficacy Outcomes for Patients with Psoriasis Who InterruptAdalimumab Therapy

Background: Adalimumab is a fully human, IgG¹ monoclonal antibodyspecific for tumor necrosis factor (TNF), a potent inflammatorycytokine.

Objective: The purpose of this analysis was to determine whetherinterruption of adalimumab therapy affected efficacy outcomes inpatients with psoriasis.

Methods: Patients with moderate to severe psoriasis (Psoriasis Area andSeverity Index [PASI] score ≧12) who previously failed topical therapyand were anti-TNF therapy—naïve were enrolled in REVEAL (RandomizedControlled Evaluation of Adalimumab Every Other Week Dosing in Moderateto Severe Psoriasis Trial), a 52-week (wk) study in which patientsreceived adalimumab 40 mg every other wk. At Wk 33 of REVEAL, patientswho had initially been randomized to adalimumab and who had achieved aPASI 75 response vs. baseline were re-randomized in a double-blindmanner to either continued adalimumab or placebo. Upon loss of adequateresponse (defined as <PASI 50 relative to baseline and at least a6-point increase in PASI score relative to Wk 33), patients wereeligible to receive adalimumab in an open-label extension (OLE). Allpatients who completed Wk 52 of REVEAL were eligible to receiveadalimumab in the OLE. This analysis compared PASI 75 response ratesbetween patients re-randomized at Wk 33 of REVEAL to placebo oradalimumab, for patients who lost or did not lose adequate responseduring REVEAL, using data from Wk 24 of the OLE relative to baseline.

Results: The percentage of patients who lost adequate response wassignificantly greater among those re-randomized to placebo (28%, 68/240)compared with those re-randomized to adalimumab (5%, 12/250) (p<0.001).Among patients re-randomized to the placebo group, PASI 75 responserates were 55% for patients who lost adequate response vs. 84% forpatients who did not lose adequate response. Among patientsre-randomized to adalimumab, PASI 75 response rates after 24 weeks ofre-treatment in OLE were 55% for patients who lost adequate response vs.83% for patients who did not lose adequate response.

Conclusions: Interruption of adalimumab was significantly associatedwith loss of adequate response. Patients who lost adequate response wereless likely to achieve their previous efficacy upon re-treatmentcompared with patients who resumed treatment without prior loss ofadequate response. These results suggest that adalimumab therapy shouldbe used continuously in psoriasis treatment.

Example 20 Benefits of Loading Dose in an Adalimumab Therapeutic Regimenfor Moderate to Severe Psoriasis

Aims: The primary goal of adalimumab treatment for moderate to severechronic plaque psoriasis is to induce and maintain clinical response. Inaddition, improving patients' quality of life with an early clinicalresponse may increase treatment compliance. This analysis employed PhaseII clinical results and a modeling and simulation approach to evaluatetime to achieving efficacious steady-state drug concentration with asingle 80-mg loading dose of adalimumab.

Methods: In a Phase II, 12-week, placebo-controlled trial, patients withmoderate to severe chronic plaque psoriasis were randomized to one ofthree arms: placebo (n=52); adalimumab 80 mg at Week 0, followed by 40mg every other week (eow) beginning at Week 1 (n=45); or adalimumab 80mg at Weeks 0 and 1, followed by 40 mg weekly beginning at Week 2(n=50).¹ Adalimumab serum concentrations were measured by ELISA atbaseline and Weeks 1, 2, 4, 8, 11, and 12.¹ A regimen of adalimumab 40mg eow without a loading dose was not studied in this trial. Therefore,a population pharmacokinetic (PK) model was developed using theconcentration data from the Phase II trial and clinical trialsimulations were then conducted to predict and compare adalimumabconcentration time profiles for two dosing regimens of interest: 40 mgeow vs. an 80-mg loading dose followed one week later by 40 mg eow.

Results: For patients in the Phase II trial, who were treated withadalimumab doses of 80 mg at Week 0 and 40 mg at Week 1, the meanadalimumab serum concentrations were 6.0 μg/mL and 8.8 μg/mL at Weeks 1and 2, respectively. By comparison, the steady-state concentrationsduring 40 mg eow dosing were 6.0 μg/mL and 6.9 μg/mL at Weeks 11 and 12.With the PK model, a total of 2,500 patients were simulated for eachregimen (with and without an 80-mg loading dose one week before thestart of a 40-mg eow dosing regimen). Clinical trial simulationsdemonstrated that a single 80-mg loading dose of adalimumab resulted insteady-state concentrations as early as Week 1, which was consistentwith Phase II study results. The simulations also indicated thatpatients to who do not receive loading doses may need approximately 12weeks to reach therapeutic steady-state concentrations.

Conclusions: Clinical trial simulations demonstrated that a single 80-mgloading dose of adalimumab may help psoriasis patients achievetherapeutic steady-state drug concentrations substantially earlier (1vs. 12 weeks) than without the loading dose.

References: ¹Gordon K B, et al. J Am Acad Dermatol. 2006;55:598-606.

Example 21: Adalimumab is Efficacious in Patients With Moderate toSevere Psoriasis Regardless of Prior Exposure or Lack of Response toSystemic Therapies

Aims: Adalimumab is a fully human monoclonal antibody specific for tumornecrosis factor. This post-hoc subanalysis assessed response toadalimumab in patients with prior exposure to systemic therapies(biologics, non-biologics, and/or oral PUVA), and in patients who failedto respond to these therapies.

Methods: Data were pooled from three double-blind, placebo-controlled,efficacy and safety studies of adalimumab for the treatment of moderateto severe psoriasis: one 12-week, Phase II study of 147 patients(M02-528), and two 16-week, Phase III studies of 271 (CHAMPION) and1,212 (REVEAL) patients. For the Phase III studies, study investigatorscollected patient histories of use of systemic psoriasis treatments overlifetime and response to systemic treatments administered within 12months of study entry (patient recall of response to treatmentsadministered more than 12 months before enrollment was not collected).For the Phase II study, patient histories of use of systemic treatmentsfor psoriasis administered within 12 months of study entry and responseto treatment within 12 months were collected. PASI response rates wereassessed through Week 12 for the Phase II study and through Week 16 forthe Phase III studies. Intention-to-treat analyses were conducted, withpatients with missing PASI responses considered non-responders.

Results: The overall Week-4/Week-16 PASI 75 response rates were 19.4%(n=966)/72.1% (n=921) for adalimumab-treated patients, and 1.4%(n=503)/8.0% (n=451) for placebo-treated patients. PASI 75 responserates at Week 4/Week 16 for patients who had received systemic therapieswere 21.7% (n=511)/72.7% (n=491) for adalimumab-treated patients, and1.5% (n=269)/8.5% (n=247) for placebo-treated patients. PASI-75 responserates at Week 4/Week 16 for patients who had failed to to respond tosystemic therapy were 15.6% (n=160)/70.4% (n=152) for adalimumab-treatedpatients, and 0% (n=69)/8.1% (n=62) for placebo-treated patients. Allresults were statistically significantly greater for adalimumab vs.placebo (p<0.001). Additional results are provided in Tables 96 and 97below.

TABLE 96 PASI 75 Response: Overall Placebo Adalimumab * Week 4 1.4%19.4% Week 8 3.8%   54% Week 12 5.8% 68.1% Week 16 8.0% 72.1% * p <0.001 adalimumab vs placebo. ITT: patients with missing PASI scoresconsidered nonresponders.

TABLE 97 PASI 75 Response: Week 16 Placebo Adalimumab Overall  8.0% (N =451)    72.1% * (N = 921) Lack of Response: MTX 0.0% (N = 17)   65.6% *(N = 32) Lack of Response: 20.0% (N = 5)  71.4% (N = 7) CyclosporineLack of Response: 50% (N = 4) 83.3% (N = 6) Oral PUVA * p < 0.001adalimumab vs placebo. ITT: patients with missing PASI scores considerednonresponders

Conclusions: Adalimumab is efficacious for the treatment ofmoderate-to-severe psoriasis. Adalimumab-treated patients who hadreceived or had failed systemic therapies had similar responses comparedwith the overall population.

Example 22: Treatment of etanercept non-responders with human TNFαantibody

Objectives: To assess the efficacy and safety of adalimumab (40 mgweekly) in psoriasis patients who were non-responders to high-dosageetanercept (50 mg twice weekly).

Methods: All patients attending a tertiary referral service for severepsoriasis who were non-responders to high-dosage etanercept (i.e.,failed to achieve at least a 50% improvement in the Psoriasis Area andSeverity Index [PASI 501 after treatment for at least 12 weeks) wereconsidered for open-label adalimumab therapy for 12 weeks. Details onclinical course and adverse events were recorded, along withmeasurements of PASI and Dermatology Life Quality Index (DLQI) atbaseline and Weeks 2, 4, 8, and 12.

Results: Four of 5 patients treated in this study with adalimumab hadreached at least PASI 50 by Week 12. Of these, 2 achieved a 75%improvement in PASI (PASI 75). No serious adverse events were reported.

Conclusions: Initial data from this open-label prospective evaluationsuggested that weekly adalimumab therapy was an effective andwell-tolerated treatment for patients with severe psoriasis who hadfailed to respond to at least 3 months of high-dosage etanercept.

Introduction

Psoriasis is an immune-mediated chronic inflammatory disease affecting2-3% of the world's population.¹′² Moreover, 20-30% of those patientshave moderate to severe disease, which has a substantial impact of onquality of life, and imposes an economic burden to health services.³Cytokines, especially tumour necrosis factor (TNF) and chemokinescontribute to the initiation and maintenance of psoriasis.⁴ Two types ofTNF antagonists are approved the treatment of moderate to severepsoriasis—soluble TNF receptors (etanercept) and monoclonal antibodies(adalimumab and infliximab). Etanercept is a recombinant fusion proteinthat consists of the soluble TNF receptor (p75) linked to the Fc portionof human IgG₁ (TNFR:Fc)⁵ and is effective in treating psoriasis andpsoriatic arthritis.^(6,7) Etanercept has been recommended by NICE inthe United Kingdom as first-line biologic therapy for patients withmoderate to severe psoriasis at a dosage of 25 mg twice weekly.

To be eligible for etanercept therapy, patients must have diseaseseverity defined by a total Psoriasis Area and Severity Index (PASI)score ≧10 and a Dermatology Life Quality Index (DLQI) >10. The patientmust have failed to respond to standard systemic therapies includingciclosporin, methotrexate, psoralen, and long-wave ultraviolet radiation(PUVA); or have been intolerant to or had contraindications for thesetreatments. Most patients with moderate to severe psoriasis will achievedisease control (i.e., reach a PASI 50) within 12 weeks. Although notapproved by NICE, high-dosage etanercept (50 mg twice weekly) islicensed and can result in efficacy for some patients.⁸ However, manypatients do not respond to even high-dosage etanercept,^(9,10) and thereare no data available on the role of other TNF blockers for psoriasispatients who fail etanercept. Adalimumab is a fully human, anti-TNFmonoclonal antibody and effective and well-tolerated in the treatment ofpsoriasis and psoriatic arthritis.^(11,12,13) In Europe, adalimumab isindicated for the treatment of moderate to severe chronic plaquepsoriasis in adult patients who failed to respond to or who have acontraindication to, or are intolerant to other systemic therapyincluding cyclosporine, methotrexate or PUVA.¹⁴ In the United States,adalimumab is approved the treatment of adult patients with moderate tosevere chronic plaque psoriasis who are candidates for systemic therapyor phototherapy, and when other systemic therapies are medically lessappropriate.¹⁵ In the present study, we assessed the efficacy and safetyof adalimumab for patients with moderate to severe psoriasis who werenon-responders to high-dosage etanercept.

Materials and Methods Study Design and Treatment Regimens

This was an open-label prospective evaluation of adalimumab (HUMIRA®,Abbott Laboratories, Abbott Park, Ill., USA). Patients who werenon-responders to etanercept were recruited from the Severe PsoriasisClinic at St John's Institute of Dermatology in London. Non-responderswere defined as patients who had failed to achieve at least 50%improvement in PASI (PASI 50) after treatment with etanercept 50 mgtwice weekly for 12 weeks. Inclusion criteria included male and femalepatients more than 18 years of age with plaque psoriasis (Table 98). Thestudy was approved by St Thomas' Research Ethics Committee, and informedconsent was obtained from all participants.

TABLE 98 Summary of Efficacy Results with 12 Weeks of Adalimumab Therapyfor Psoriasis Patient Number 1 2 3 4 5 Sex Female Male Male Male MaleAge (yrs) 54 51 42 45 42 Weight (kg) 96.5 85.4 105.35 111.0 67.35Duration of psoriasis (yrs) 4 21 22 30 28 Psoriatic arthritis Yes No YesNo No PASI/DLQI Week 0 22.6/19 35.8/11   45.9/30  14.7/11  32.2/14PASI/DLQI Week 2 23.4/17 23.6/10   21.6/30 11.2/9 22.9/5 PASI/DLQI Week4 26.7/16 20.1/5   8.70/28 7.00/4 23.6/7 PASI/DLQI Week 8 18.2/1512.3/3   Not 8.40/0 19.6/9 recorded PASI/DLQI Week 12 21.2/6  6.30/1   3.3/26 7.10/2 15.2/6 % Improvement in PASI/DLQI   6/68 82/91   93/13  52/82   53/57 from baseline to Week 12 ESR (mm/hr)/CRP (mg/L)   36/2034/<5   20/10   44/6    2/<5 Week 0 ESR (mm/hr)/CRP (mg/L)  13/7 12/<5Not   12/<5    2/<5 Week 12 recorded/<5 PASI, psoriasis area severityindex; DLQI, Dermatology Life Quality Index; ESR, erythrocytesedimentation rate; CRP, C-reactive protein.

Prior to inclusion into the trial, all patients underwent a fullclinical history, physical examination, and investigations according toBritish Association of Dermatologists (BAD) guidelines⁸ as shown in FIG.11. All patients fulfilled the inclusion criteria.

Intervention

Adalimumab 80-mg loading doses were administered to the first 5 patientswho enrolled in this investigator-initiated study at Weeks 0 and 1,followed by adalimumab to 40 mg weekly from Weeks 2-11. The study periodwas 12 weeks. Adalimumab was initiated between 4 and 38 weeks (mean 12.8weeks) following cessation of etanercept. Patients were able to withdrawfrom the study at any stage. They were permitted to continue topicaltreatments at stable dosages throughout the study, but could not useconcomitant systemic therapy for psoriasis.

Patients were provided an information pack that included a “HUMIRATreatment Guide,” as well as a “HUMIRA Drug Information Leaflet.” Theywere observed at Weeks 0, 2, 4, 8, and 12. At each clinical visit PASI,DLQI, and percentage body surface area (% BSA) affected were assessedand recorded. In addition, patients received medical assessmentstogether with monitoring laboratory investigations (FIG. 11).

Efficacy assessments

The primary efficacy endpoint of the study was PASI 50 response rate atWeek 12 of adalimumab therapy. The secondary efficacy endpoint was PASI75 response rate at Week 12.

Results Patients

Five patients completed the 12-week trial (Table 1). Each patient hadsevere psoriasis as defined by a PASI ≧10 and DLQI >10 and had failed toachieve at least a PASI 50 after treatment with etanercept 50 mg twiceweekly for 12 weeks. All five patients had a diagnosis of chronic plaquepsoriasis.

Primary Efficacy

The primary efficacy parameter (PASI 50 at Week 12) was achieved by 4 of5 patients. Patient 2 achieved PASI 50 by Week 8; Patient 3 by Week 4;Patient 4 by Week 2; and Patient 5 by Week 12. Patient 1 was anon-responder to high-dosage to adalimumab (FIG. 12)

Secondary Efficacy

The secondary efficacy parameter (PASI 75 at Week 12) was achieved bytwo patients. Patient 2 reached a PASI 75 at Week 12, and Patient 4 didso at Week 4.

Patient-Reported Outcomes

All five patients achieved a reduction in their DLQI scores, with a meandecrease of 8.8 at Week 12 (FIG. 13).

Adverse Events

No serious adverse events were reported.

Discussion

This is the first prospective study of patients with moderate to severepsoriasis who had failed high-dosage etanercept. At Week 12, 80% hadachieved at least PASI 50, and of these, two had achieved PASI 75, withone patient achieving almost complete clearance. Previous studiessupport the theory that patients who have failed previous biologicaltherapies can benefit from adalimumab.^(16,17) Adalimumab has recentlyreceived NICE approval as a recommended treatment option for adults withplaque psoriasis for whom anti-TNF treatment is being considered. Therecommended dosage is an initial loading dose of 80 mg (subcutaneously,followed by 40 mg every other week starting 1 week after initial dose.In this study, we used high-dosage adalimumab (40 mg weekly) followingthe loading dose.

Since our group of patients were “high-need” patients who had failedhigh-dosage etanercept, we decided to use adalimumab 40 mg weekly.Following our 12-week study, the dosage of adalimumab was reduced to 40mg every other week. This preliminary study indicates that adalimumab,at a dosage greater than the currently recommended schedule, is aneffective treatment for patients with severe psoriasis who had failed torespond to at least 12 weeks of high-dosage etanercept.

This study adds treatment options for patients with unmet medical needwho pose a clinical challenge. Sequential biological therapy has beenreported to be successful,¹⁸ and our study supports this. Failure orloss of efficacy to one biologic therapy does not imply that alternativebiologics, even ones, from the same class, will be ineffective as well.

REFERENCES

-   1. Smith C H, Barker J N. Psoriasis and its management. BMJ.    2006;19:380-4.-   2. Griffiths C E, Barker J N. Pathogenesis and clinical features of    psoriasis. Lancet 2007;370:263-71.-   3. Griffiths C E, Clark C M, Chalmers R J, et al. A systematic    review of treatments for severe psoriasis. Health Technol Asses    2000;4:1-125.-   4. Nickoloff B J, Xin H, Nestle F O, Qin J-Z. The cytokine and    chemokine network in psoriasis. Clinic in Dermatol 2007;25:568-73.-   5. Moreland L W, Baumgartner S W, Schiff M H, et al. Treatment of    rheumatoid arthritis with a recombinant human tumor necrosis factor    receptor (p75)-Fc fusion protein. N Engl J Med 1997;337:141-7.-   6. Iyer S, Yamauchi P, Lowe N J. Etanercept for severe psoriasis and    psoriatic arthritis: observations on combination therapy. Br J    Dermatol 2002;146:118-21.-   7. Simpson D, Scott L J. Adalimumab in psoriatic arthritis. Drugs    2006;66:1487-96.-   8. Smith C H, et al. British association of Dermatologists    guidelines for the use of biological interventions in    psoriasis 2005. Br J Dermatol 2005;153:486-97.-   9. de Groot M, Appelman M, Spuls P I, de Rie M A, Bos J D. Initial    experience with routine administration of etanercept in psoriasis.Br    J Dermatol 2006;155:808-14.

10. Ahmad K, Rogers S.Two years of experience with etanercept inrecalcitrant psoriasis. Br J Dermatol. 2007;156:1010-4.

-   11. Sladden M J, Mortimer N J, Hutchinson PE. Extensive plaque    psoriasis successfully treated with adalimumab. Br J Dermatol    2005;152:1091-2.-   12. Pitarch G, Sanchez-Carazo J L, Mahiques L, et al. Treatment of    psoriasis with adalimumab. Clin Exp Dermatol 2006;1:1-5.-   13. Gladman D D, Ritchlin C T, Mease P J, et al. Adalimumab for the    treatment of patients with moderately to severely active psoriatic    arthritis. Arthritis Rheum 2005;52:3279-89.-   14. HUMIRA® (adalimumab) Summary of Product Characteristics.    Available at    www.emea.europa.eu/humandocs/Humans/EPAR/humira/humira.htm. Accessed    Dec. 19, 2008.-   15. HUMIRA® (adalimumab) prescribing information. Abbott Park, Ill.    Abbott Laboratories, 2008. Available at    www.rxabbott.com/pdf/humira.pdf. Accessed Dec. 19, 2008.-   16. Pitarch J L, Sanchez-Carazo J L, Mahiques L, Perez-Ferriols M a,    Fortea J M. Treatment of psoriasis with adalimumab. Clin Exp    Dermatol 2007;32:18-22.-   17. Van L, Modi S V, Yang D J, Hsu S. Sustained efficacy and safety    of adalimumab in psoriasis treatment: a retrospective study of 49    patients with and without a history of TNF-alpha antagonist    treatment. Arch Dermatol 2008;144;804-6.-   18. Barde C, Thielen A M, Kuenzli S, Saurat J-H. Treatment of plaque    psoriasis by sequential therapy with two “biologics”: the “hit and    run” approach, a report of two cases. Br J Dermatol 2006;155:211-13.

Example 23: Efficacy of human TNFα antibody for treating skin disorderin patients having suboptimal response to systemic therapy orphototherapy

Objective: The purpose of this trial was to study the efficacy andsafety of adalimumab in psoriasis patients with suboptimal response tosystemic therapy (etanercept [ETN] or methotrexate [MTX]) orphototherapy.

Methods: This 16-week, multicenter, open-label, Phase Mb trial enrolledpatients with chronic plaque psoriasis who were having a suboptimalresponse to ETN (Physician's Global Assessment [PGA]≧mild with ≧6 monthsof therapy, or ≧3 months of therapy and deterioration of efficacy), MTX(PGA ≧mild with ≧4 months of therapy), or narrow-band ultraviolet B(NB-UVB) phototherapy (PGA ≧moderate with ≧2 months of therapy). Perprotocol, patients discontinued therapy 2 weeks (ETN) or 1 week (MTX,NB-UVB) before initiating adalimumab at the approved dose (80 mg at Week0, then 40 mg every other week from Week 1). The primary endpoint wasthe proportion of patients who achieved PGA of clear or minimal at week16. A secondary endpoint was the proportion achieving ≧1 grade of PGAimprovement. Safety was assessed throughout the study. Efficacy analyseswere intention to treat, with nonresponder imputation used for missingdata. Efficacy and safety results were analyzed overall and for eachprior-treatment group.

Results: A total of 152 patients enrolled in the study (ETN, N=82; MTX,N=41; NB-UVB, N=29). The distribution of PGA scores at baseline was:very severe 0.7%, severe 15.8%, moderate 65.1%, mild 17.1%, minimal1.3%, clear 0%. At week 16, PGA of clear or minimal was achieved in52.0% (95% CI 43.7, 60.1) of all patients and 48.8% (37.6, 60.1), 61.0%(44.5, 75.8), and 48.3% (29.4, 67.5) of patients in the ETN, MTX, andNB-UVB groups, respectively. At week 16, ≧1 grade improvement in PGA wasachieved by 75.0% (67.3, 81.7) of all patients and 72.0% (60.9, 81.3),78.0% (62.4, 89.4), and 79.3% (60.3, 92.0) in the ETN, MTX, and NB-UVBgroups, respectively. Four patients (2.6%; 2 MTX, 2 ETN)experienced >25% worsening in Psoriasis Area to and Severity Indexscores. One subject (NB-UVB) had a serious infection (cellulitis); nomalignancies were reported.

Conclusions: Approximately half of patients with suboptimal response toETN, MTX, or NB-UVB achieved a clinically relevant improvement inpsoriasis 16 weeks after transitioning to adalimumab. Patients hadacceptable safety outcomes and a low risk of flare, despite immediatediscontinuation of prior therapy and a short washout.

Equivalents

Those skilled in the art will recognize, or be able to ascertain usingno more than routine experimentation, many equivalents to the specificembodiments of the invention described herein. Such equivalents areintended to be encompassed by the following claims. The contents of allreferences, patents and published patent applications cited throughoutthis application are incorporated herein by reference.

1. A method for treating a skin disorder associated with detrimentalTNFα activity in a subject who has failed to respond to or has lostresponsiveness to a biologic therapy, comprising administering to thesubject who has failed to respond to or has lost responsiveness to thebiologic therapy, a human TNFα antibody, or an antigen-binding portionthereof, such that the skin disorder is treated.
 2. A method ofdetermining the efficacy of a human TNFα antibody, or an antigen bindingportion thereof, for treating psoriasis in a subject who has failed torespond to or has lost responsiveness to a biologic therapy comprising,determining the PASI50 response of a patient population who has failedto respond to or has lost responsiveness to a biologic therapy, and whowere administered the human TNFα antibody, or antigen binding portionthereof, wherein a statistically significant improvement in the PASI50of the patient population indicates that the TNFα inhibitor is effectivefor treating psoriasis in the subject.